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Acute Pericarditis/ ECG conference. Jimmy Klemis, MD Jan 8, 2002. Pericardium. Visceral / serous Direct contact with epicardium (ST elev) single layer mesothelial cells Parietal / fibrous mesothelial and fibrous layer. Pericardial Anatomy. Visceral – transparent

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acute pericarditis ecg conference

Acute Pericarditis/ECG conference

Jimmy Klemis, MD

Jan 8, 2002

pericardium
Pericardium
  • Visceral / serous
    • Direct contact with epicardium (ST elev)
    • single layer mesothelial cells
  • Parietal / fibrous
    • mesothelial and fibrous layer
pericardial anatomy
Pericardial Anatomy

Visceral – transparent

Parietal – translucent

Transverse sinus – curved probe

etiology acute pericarditis
Etiology – Acute Pericarditis
  • Infectious
    • Viral : Coxsackie, Echo, EBV, Influenza, HIV
    • Bacterial: TB, staph, hemophillus, pneumococcal, salmonella
    • Fungal/other: histo/blasto/coccidio, rickettsia
  • Rheumatologic
    • SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, Scleroderma, PAN
  • Neoplastic
    • Primary: angiosarcoma, mesothelioma
    • Metastatic: breast, lung, lymphoma, melanoma, leukemia
  • Immunologic
    • Celiac sprue, Inflammatory Bowel Disease
  • Drug
    • Hydralizine, Procainamide
  • Other
    • MI, Dressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection
    • Uremic, Post Radiation
    • IDIOPATHIC
acute pericarditis clinical
Acute Pericarditis – Clinical
  • History
    • preceding viral illness, etc
  • Symptoms
    • Chest pain
  • Signs
    • Friction Rub
  • ECG
    • early: PR / ST changes
    • late: isoelectric ST/ T inv
history
History
  • Often preceding viral illness 1-2wk prior
  • Chest Pain
    • Sudden, sharp,pleuritic, constant
    • worse supine/ L lat decub, relief sitting up
    • radiation: back, trapezius ridge
    • symptoms usually resolve by 2 weeks, ECG abnormalities may persist for months
auscultory rub s
Auscultory – Rub(s)
  • Endopericardial (classic)
    • “triphasic”: atrial sys, ventricular sys, early diastole
    • may only hear 2 phase (afib or tachycardia) or 1
    • loudest LSB, raised extremities/increased venous return
  • Pleuropericardial
    • “exopericardial”, extension into adjacent structures
    • marked resp variation, musical quality
  • Conus
    • dilation of pulm conus in hyperactive heart
    • PE, thyroid storm, acute beriberi
  • Pneumohydropericardium
    • air/gas overlying pcard fluid
    • metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)
slide8
ECG
  • PR depression
  • ST elevation
    • concave up, ST/T V6 >.25, no reciprocal
  • DDx:
    • Acute MI
    • Early Repolarization
    • Myocarditis
    • Aneurysm
    • other: Brugada, BBB
acute pericarditis stages
Acute Pericarditis - Stages
  • Stage I
    • first few days  2 weeks
    • ST elev, PR depression
    • up to 50% of pt with sxs/rub do NOT have/evolve stage I1
  • Stage II
    • last days  weeks
    • ST returns to baseline, flat T
  • Stage III
    • after 2-3 weeks, lasts several weeks
    • T wave inversion
  • Stage IV
    • lasts up to several months
    • gradual resolution of T wave changes

1 Spodick DH, Pericardial Disease. Braunwauld 6th

acute pcard stage i ii
Acute PCARD – Stage I, II

60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs,

* Marriott’s Practical ECG 10th ed, p 208

acute pcard stage iii
Acute PCARD – Stage III

19 y/o Female after 1 wk in hospital with Acute Pericarditis

cardiac isoenzymes helpful
Cardiac Isoenzymes - ? helpful
  • 2 year study, ER based1
    • 14 pt with 2/3 findings (CP typical for PCARD, rub, and ECG changes c/w PCARD)
    • 71% had elevated TropI (pk 21) with negative CAD workup
  • Not reliable to differentiate MI vs PCARD

1Brandt RR, et al. Am J Card 2001, June 1

treatment
Treatment
  • NSAIDS/ASA
    • ASA 650 q3-4hr
    • Ibuprofen 300-600 q 6-8 hrs x 1-4days
      • Avoid Indocin, reduces CBF
  • Steroids
    • if no response after 48hr NSAID
    • use concurrent NSAID
  • Colchicine
    • .6 q12 chronic +/- NSAID
    • useful in recurrent pericarditis
    • symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001)

in largest multicenter trial to date1

    • Anecdotal evidence of benefit in Acute PCARD, effusion

1Adler Y, et al. Circulation, 1998 June 2

complications
Complications
  • Pericardial Effusion/Tamponade
  • Constrictive Pericarditis
    • can be “transient” – 10% may have transient sxs within 1st month, resolves by 3 months
  • Recurrent Pericarditis (20-25%)
    • Rx – NSAIDS/Colchicine +/- steroids
gross pathology
Gross Pathology

“Bread & Butter” appearance

Fibrinous stranding

ecg quiz
ECG Quiz

Acute Pericarditis, Stage I

ecg quiz 2
ECG quiz 2

Acute Ant MI

ecg quiz 3
ECG quiz 3

Early Repolarization

ecg quiz 4
ECG quiz 4

Early Repolarization

ecg quiz 5
ECG Quiz 5

Pericardial dz, diffuse ST elev

ecg quiz 6a
ECG Quiz 6a

Acute antseptal MI

ecg quiz 7
ECG Quiz 7

Early Repolarization

ecg quiz 8
ECG quiz 8

Incomplete RBBB