Acute Pericarditis/Acute Pericarditis/ECG conferenceECG conference

Jimmy Klemis, MDJimmy Klemis, MD

Jan 8, 2002Jan 8, 2002

PericardiumPericardium

Visceral / serous Visceral / serous – Direct contact with epicardium (ST elev)Direct contact with epicardium (ST elev)– single layer mesothelial cellssingle layer mesothelial cells

Parietal / fibrousParietal / fibrous– mesothelial and fibrous layermesothelial and fibrous layer

Pericardial AnatomyPericardial AnatomyVisceral – transparent

Parietal – translucent

Transverse sinus – curved probe

Etiology – Acute PericarditisEtiology – Acute Pericarditis InfectiousInfectious

– Viral : Viral : CoxsackieCoxsackie, Echo, EBV, Influenza, HIV, Echo, EBV, Influenza, HIV– Bacterial: TB, staph, hemophillus, pneumococcal, salmonellaBacterial: TB, staph, hemophillus, pneumococcal, salmonella– Fungal/other: histo/blasto/coccidio, rickettsiaFungal/other: histo/blasto/coccidio, rickettsia

RheumatologicRheumatologic– SLESLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, , Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis,

Scleroderma, PANScleroderma, PAN NeoplasticNeoplastic

– Primary: angiosarcoma, mesotheliomaPrimary: angiosarcoma, mesothelioma– Metastatic: breast, lung, lymphoma, melanoma, leukemiaMetastatic: breast, lung, lymphoma, melanoma, leukemia

ImmunologicImmunologic– Celiac sprue, Inflammatory Bowel DiseaseCeliac sprue, Inflammatory Bowel Disease

DrugDrug– HydralizineHydralizine, , ProcainamideProcainamide

OtherOther– MI, MI, Dressler’s, Post PericardiotomyDressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection, Chest Trauma, Aortic dissection– UremicUremic, Post Radiation, Post Radiation– IDIOPATHICIDIOPATHIC

Acute Pericarditis – Clinical Acute Pericarditis – Clinical

HistoryHistory– preceding viral illness, etcpreceding viral illness, etc

SymptomsSymptoms– Chest painChest pain

SignsSigns– Friction Rub Friction Rub

ECGECG– early: PR / ST changesearly: PR / ST changes– late: isoelectric ST/ T invlate: isoelectric ST/ T inv

HistoryHistory

Often preceding viral illness 1-2wk priorOften preceding viral illness 1-2wk prior Chest Pain Chest Pain

– Sudden, sharp,pleuritic, constantSudden, sharp,pleuritic, constant– worse supine/ L lat decub, relief sitting upworse supine/ L lat decub, relief sitting up– radiation: back, trapezius ridgeradiation: back, trapezius ridge– symptoms usually resolve by 2 weeks, ECG symptoms usually resolve by 2 weeks, ECG

abnormalities may persist for monthsabnormalities may persist for months

Auscultory – Rub(s)Auscultory – Rub(s)

Endopericardial Endopericardial (classic)(classic)– ““triphasic”: atrial sys, ventricular sys, early diastoletriphasic”: atrial sys, ventricular sys, early diastole– may only hear 2 phase (afib or tachycardia) or 1may only hear 2 phase (afib or tachycardia) or 1– loudest LSB, raised extremities/increased venous returnloudest LSB, raised extremities/increased venous return

PleuropericardialPleuropericardial– “ “exopericardial”, extension into adjacent structuresexopericardial”, extension into adjacent structures– marked resp variation, musical qualitymarked resp variation, musical quality

ConusConus– dilation of pulm conus in hyperactive heartdilation of pulm conus in hyperactive heart– PE, thyroid storm, acute beriberiPE, thyroid storm, acute beriberi

PneumohydropericardiumPneumohydropericardium– air/gas overlying pcard fluidair/gas overlying pcard fluid– metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)

ECGECG

PR depressionPR depression ST elevationST elevation

– concave up, ST/T V6 >.25, no reciprocalconcave up, ST/T V6 >.25, no reciprocal DDx: DDx:

– Acute MIAcute MI– Early RepolarizationEarly Repolarization– MyocarditisMyocarditis– AneurysmAneurysm– other: Brugada, BBBother: Brugada, BBB

ECGECG

Acute Pericarditis - StagesAcute Pericarditis - Stages

Stage IStage I– first few days first few days 2 weeks 2 weeks– ST elev, PR depressionST elev, PR depression– up to 50% of pt with sxs/rub do NOT have/evolve stage Iup to 50% of pt with sxs/rub do NOT have/evolve stage I11

Stage IIStage II– last days last days weeks weeks– ST returns to baseline, flat TST returns to baseline, flat T

Stage IIIStage III– after 2-3 weeks, lasts several weeksafter 2-3 weeks, lasts several weeks– T wave inversionT wave inversion

Stage IVStage IV– lasts up to several monthslasts up to several months– gradual resolution of T wave changesgradual resolution of T wave changes

1 Spodick DH, Pericardial Disease. Braunwauld 6th

Acute PCARD – Stage I, IIAcute 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 IIIAcute PCARD – Stage III

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

DDx: PCARD vs RepolDDx: PCARD vs Repol

Acute Acute PericarditisPericarditis

Early Early RepolarizationRepolarization

SexSex EitherEither Usually MaleUsually Male

AgeAge AnyAny Usually < 40Usually < 40

PR segment devPR segment dev CommonCommon UncommonUncommon

T wavesT waves nl, bluntnl, blunt tall, peakedtall, peaked

J-ST / T ampl J-ST / T ampl V6V6

> 25%> 25% <25%<25%

Tallest Tallest precordial Rprecordial R

Usually V5Usually V5 Usually V4Usually V4

DDx: PCARD vs MIDDx: PCARD vs MI

PericarditisPericarditis Angina, ischemiaAngina, ischemia

J-STJ-ST Diffuse concave Diffuse concave elevation w/o reciprocal elevation w/o reciprocal changeschanges

Localized, convex, w/ Localized, convex, w/ reciprocal changes in reciprocal changes in infarctinfarct

PR depressionPR depression FrequentFrequent Almost neverAlmost never

Q wavesQ waves Not usual, unless with Not usual, unless with infarctinfarct

Common with q wave Common with q wave infarctinfarct

T wavesT waves Inverted after J returns Inverted after J returns to baselineto baseline

Inverted while ST still Inverted while ST still elevatedelevated

ArrhythmiaArrhythmia RareRare FrequentFrequent

Conduction Conduction disturbancesdisturbances

RareRare frequentfrequent

Cardiac Isoenzymes - ? helpfulCardiac Isoenzymes - ? helpful

2 year study, ER based2 year study, ER based11

– 14 pt with 2/3 findings (CP typical for PCARD, 14 pt with 2/3 findings (CP typical for PCARD, rub, and ECG changes c/w PCARD)rub, and ECG changes c/w PCARD)

– 71% had elevated TropI (pk 21) with negative 71% had elevated TropI (pk 21) with negative CAD workupCAD workup

Not reliable to differentiate MI vs PCARDNot reliable to differentiate MI vs PCARD

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

TreatmentTreatment

NSAIDS/ASANSAIDS/ASA– ASA 650 q3-4hrASA 650 q3-4hr– Ibuprofen 300-600 q 6-8 hrs x 1-4daysIbuprofen 300-600 q 6-8 hrs x 1-4days

Avoid Indocin, reduces CBFAvoid Indocin, reduces CBF SteroidsSteroids

– if no response after 48hr NSAIDif no response after 48hr NSAID– use concurrent NSAIDuse concurrent NSAID

ColchicineColchicine– .6 q12 chronic +/- NSAID.6 q12 chronic +/- NSAID– useful in recurrent pericarditisuseful in recurrent pericarditis– symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001)symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001)

in largest multicenter trial to datein largest multicenter trial to date11

– Anecdotal evidence of benefit in Acute PCARD, effusionAnecdotal evidence of benefit in Acute PCARD, effusion

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

ComplicationsComplications

Pericardial Effusion/TamponadePericardial Effusion/Tamponade Constrictive PericarditisConstrictive Pericarditis

– can be “transient” – 10% may have transient can be “transient” – 10% may have transient sxs within 1sxs within 1stst month, resolves by 3 months month, resolves by 3 months

Recurrent Pericarditis (20-25%)Recurrent Pericarditis (20-25%)– Rx – NSAIDS/Colchicine +/- steroidsRx – NSAIDS/Colchicine +/- steroids

Gross PathologyGross Pathology

“Bread & Butter” appearance Fibrinous stranding

Acute PCARD – Stage IAcute PCARD – Stage I

ECG QuizECG QuizAcute Pericarditis, Stage I

ECG quiz 2ECG quiz 2Acute Ant MI

ECG quiz 3ECG quiz 3Early Repolarization

ECG quiz 4ECG quiz 4Early Repolarization

ECG Quiz 5ECG Quiz 5

Pericardial dz, diffuse ST elev

ECG Quiz 6ECG Quiz 6

ECG Quiz 6aECG Quiz 6aAcute antseptal MI

ECG Quiz 7ECG Quiz 7

Early Repolarization

ECG quiz 8ECG quiz 8

Incomplete RBBB