2. Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

3. Outline 1) Anatomy of pericardium 2) Overview of pericardial disease 3) Etiology 4) Clinical presentation 5) Ancillary diagnostics 6) Echocardiography in evaluation

4. Anatomy Normal amount of pericardial fluid: 15-50 cc Two layers: Outer layer is the parietal pericardium and consists of layers of fibrous and serous tissue Inner layer is visceral pericardium and consists of serous tissue only

5. Pericardium Fibroelastic sac consisting of 2 layers Fibroelastic sac consisting of 2 layers Visceral at epicardial side Visceral at epicardial side Parietal at mediastinal side Parietal at mediastinal side Pericardial fluid formed from ultrafiltrate of plasma Pericardial fluid formed from ultrafiltrate of plasma

6. Diseases of the Pericardium Acute Fibrinous Pericarditis Acute Fibrinous Pericarditis Pericardial Effusion Pericardial Effusion Without cardiac tamponade Without cardiac tamponade Cardiac tamponade Cardiac tamponade Recurrent Pericarditis Recurrent Pericarditis Constrictive Pericarditis Constrictive Pericarditis

7. Epidemiology of Acute Pericarditis 0.1% of hospitalized patients 0.1% of hospitalized patients 5% of patients admitted to Emergency Department for non-acute myocardial infarction chest pain 5% of patients admitted to Emergency Department for non-acute myocardial infarction chest pain

8. Major Causes of Pericardial Disease 1)Infection2)Radiation3)Neoplasm4)Cardiac5)Trauma6)Autoimmune7)Drugs8)Metabolic *viral, autoreactive, and neoplastic most common diagonsis

9. Etiology of Acute Pericarditis: Infectious a) viral -adenovirus-enterovirus-cytomegalovirus-influenza -hepatitis B -herpes simplex -echovirus-mumps b) mycoplasma c)Fungal d)Parasitic e)Bacterial -staph -strep -pneumococcus -haemophilus -neisseria -chlamydia -legionella -tuberculous -lyme disease

10. Etiology: continued 2) Radiation 3)Neoplasm-metastatic -primary cardiac -paraneoplastic4)Cardiac -early infarction -Dressler’s-myocarditis -aortic dissection 5)Trauma -blunt -iatrogenic (perforations, post-surg) 6)Autoimmune -rheumatic disease -non-rheumatic -Wegners, sarcoid, IBD

11. Etiology: continued 7)Drugs -drug induced lupus hydralazineisoniazidprocainamide-doxorubicin-phenytoin 8)Metabolic -hypothyroid -uremia -ovarian hyperstimulation

12. Lab Testing Of note, the historic yield of diagnostic evaluation is low, typically only in approximately 16% of patients is etiology determined. Of note, the historic yield of diagnostic evaluation is low, typically only in approximately 16% of patients is etiology determined. More recently, evaluation of pericardial fluid and tissue with tumor markers, PCR, immunohistochemistry, flourescence-activated cell sorting has shown a trend toward higher yield of diagnosis More recently, evaluation of pericardial fluid and tissue with tumor markers, PCR, immunohistochemistry, flourescence-activated cell sorting has shown a trend toward higher yield of diagnosis

13. Diagnosis: Presence of two of the following necessary Chest pain Chest pain Sudden onset Sudden onset localized to anterior chest wall localized to anterior chest wall pleuritic pleuritic sharp sharp Positional: may improve if pt leans forward, worse with lying flat Positional: may improve if pt leans forward, worse with lying flat Cardiac auscultation: Pericardial friction rub Cardiac auscultation: Pericardial friction rub Present in up to 85% of pts with pericarditis without effusion Present in up to 85% of pts with pericarditis without effusion friction of the two inflamed layers of pericardium, typically triphasic rub, heard with diaphragm of stethoscope at left sternal border friction of the two inflamed layers of pericardium, typically triphasic rub, heard with diaphragm of stethoscope at left sternal border Characteristic ECG changes Characteristic ECG changes Pericardial effusion Pericardial effusion

14. Pertinent Lab Results Elevated C reactive protein level (such a strong correlation that normal CRP makes acute pericarditis diagnosis less likely) Elevated C reactive protein level (such a strong correlation that normal CRP makes acute pericarditis diagnosis less likely) Elevated CK, CK-MB, and Troponin (can be normal) Elevated CK, CK-MB, and Troponin (can be normal) Often elevated Troponin alone Often elevated Troponin alone Indicates inflammation of myocardium just beneath the visceral pericardium Indicates inflammation of myocardium just beneath the visceral pericardium Not associated with worse outcomes Not associated with worse outcomes Leukocytosis Leukocytosis

15. ECG Findings: 60% of patients Stage 1: hours to days Diffuse ST elevation -sensitive v5-v6, I, II ST depression I/aVR PR elevation aVR PR depression diffuse -especially v5-v6 PR change is marker of atrial injury Stage 2: Normalization

16. ECG changes over weeks Stage 3: Stage 3: Diffuse T wave inversions Diffuse T wave inversions ST segments isoelectric ST segments isoelectric Stage 4: EKG may normalize T wave inversions may persist indefinitely

17. STEMI or Pericarditis by ECG ST elevation in pericarditis ST elevation in pericarditis Starts at J point Starts at J point Rarely exceeds 5mm Rarely exceeds 5mm Retains normal concavity Retains normal concavity Non-localizing Non-localizing Arrhythmias very unlikely in pericarditis (suggest myocarditis or MI) Arrhythmias very unlikely in pericarditis (suggest myocarditis or MI)

18. Acute Pericarditis 51yo man with acute onset sharp substernal chest pain two days prior

19. Pericardial Effusion Low voltage and Electric Alternans

20. Echocardiographic Findings Echo is typically normal in acute pericarditis unless associated with pericardial effusion Echo is typically normal in acute pericarditis unless associated with pericardial effusion

21. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article Recommended specific circumstances for use of echocardiography in pericardial disease Recommended specific circumstances for use of echocardiography in pericardial disease

22. Class I Recommendations 1. Patients with suspected pericardial disease, including effusion, constriction, or effusive- constrictive process. 2. Patients with suspected bleeding in the pericardial space, eg, trauma, perforation, etc.

23. Class I (continued) 3. Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal directed to answer a specific clinical question 4. Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea.

24. Class IIa 1)Follow-up studies to detect early signs of tamponade in the presence of large or rapidly accumulating effusions. A goal-directed study may be appropriate. 2)Echocardiographic guidance and monitoring of pericardiocentesis.

25. Class IIb 1) Postsurgical pericardial disease, including postpericardiotomy syndrome, with potential for hemodynamic impairment. 2) In the presence of a strong clinical suspicion and nondiagnostic TTE, TEE assessment of pericardial thickness to support a diagnosis of constrictive pericarditis.

26. Effusion: 2D Parasternal Long

27. Pericardial Fat Pad Often pericardial fat pads can be seen in this view anterior to the RVOT Often pericardial fat pads can be seen in this view anterior to the RVOT Fat pads usually not seen elsewhere Fat pads usually not seen elsewhere

28. Effusion: Parasternal Short Axis

29. Posterior Effusions Pericardial effusions can track posteriorly toward sinus Pericardial effusions can track posteriorly toward sinus In this case, may only be seen in axial 4 chamber view In this case, may only be seen in axial 4 chamber view

31. Effusion: 2D Apical

32. Tamponade Hypotension caused by pericardial fluid under pressure Hypotension caused by pericardial fluid under pressure Diagnostic techniques Diagnostic techniques 2D looking for RA/RV collapse during diastole 2D looking for RA/RV collapse during diastole M-mode for RA/RV collapse during diastole M-mode for RA/RV collapse during diastole Doppler of Mitral and Tricuspid inflow Doppler of Mitral and Tricuspid inflow Mitral inflow to decrease by 25% with inspiration Mitral inflow to decrease by 25% with inspiration Tricuspid inflow increased by 40% with inspiration Tricuspid inflow increased by 40% with inspiration IVC diameter fails to increase with inspiration IVC diameter fails to increase with inspiration

33. Tamponade: 2D

34. Tamponade: M-Mode

35. Tamponade: Doppler Mitral Inflow

36. Chest X ray Normal in patients with acute pericarditis unless pericardial effusion is present Enlarged cardiac silhouette Requires 200cc of fluid

37. Fibrinous Pericarditis