Pericarditis and Myocarditis. Sheba Medical Center Cardiology Department Carlyn Wallis

Transcription

1 Pericarditis and Myocarditis Sheba Medical Center Cardiology Department Carlyn Wallis

2 Outline Pericarditis Normal function of the pericardium Pathophysiology + Etiology Clinical Presentation Differential diagnosis Work up Treatment Complications Myocarditis Normal function of the myocardium Pathophysiology + Etiology Clinical presentation Differential diagnosis Work up Treatment Complications

3 Layers of the heart The heart wall is arranged into three layers

4 Layers of the heart Pericardium is the sac that encloses the heart. It is also known as the outermost layer of the heart. Myocardium is the thickest layer of the heart made of pure muscle Endocardium is the thin layer of tissue heart that lines the heart s chambers and valves. The cardiac conduction system is located in this layer of the heart.

5 Normal function of the Pericardium Outer fibrous layer (Parietal pericardium) Inner serous layer (Viseral pericardium) Normally contains 20-50mL of ultrafiltrate of plasma

6 Normal function of Pericardium 3 main functions:- Mechanical - Promotes cardiac efficiency by limiting acute dilation and maintaining ventricular compliance Membranous - Shields heart by reducing external friction and acts as protective barrier against spread of infection and malignancy Ligamentous Anatomically fixes the heart

7 Pericarditis Pericarditis is inflammation of the pericardium There are different types of Pericarditis :- Acute Pericarditis Chronic Pericarditis Chronic-effusive Pericarditis

8 Pathophysiology Acute Pericarditis The Pericardium is acutely inflamed and has infiltrates on polymorphonuclear (PMN) leukocytes and pericardial vascularization. Often manifests with a fibrinous reaction with exudates and adhesions. May develop a serous or hemorrhagic effusion

9 Acute Pericarditis - Etiology Serous pericarditis non-infectious inflammation e.g. Rheumatoid arthritis (RA) and Systemic lupus erythematosus (SLE) Fibrinous + serofibrinous pericarditis (most common type of pericarditis) acute Myocardial infacrtion, postinfarction (including dressler syndrome), uremia, radiation, RA, SLE and trauma. Also severe infection.

10 Acute Pericarditis - Etiology Purulent or suppurative pericarditis from causative organisms may arise from direct extension, hematogenous seeding, lymphatic extension or by direction introduction during cardiotomy. Immunosuppression facilitates this condtion. Haemorrhagic pericarditis Tuberculosis, direct neoplastic invasion, severe bacterial infections or in patients with bleeding diathesis. It is common after cardiac surgery and may cause cardiac tamponade.

11 Clinical presentation - History Chest pain (cardinal symptom!!) usually precordial or retrosternal with referral to neck, trapezius, left shoulder and arm. Usually pleuritic chest pain but it can range from sharp, dull, aching, burning or pressing and intensity varies between patients. Pain is worse on inspiration, when lying flat, or durinf swallowing. Pain may be relieved by leaning forward while seated. Palpitations may also be the presenting complaint.

12 Clinical presentation - History Associated signs and symptoms include:- Low-grade intermittent fever Dyspneoa Tachypnoea Cough Dysphagia Tuberculous pericarditis B-symptoms Fever, night sweats, and weight loss *Children may present with abdominal pain*

13 Clinical Presentation - Examination Pericardial friction rub (Pathognomonic for acute pericarditis!!!) Best heard on auscultation with diaphragm at left lower sternal edge or apex with patient sitting up and leaning forward Dyspnoea Tachypnoea Ewart sign (dullness and bronical breathing between tip of left scapula and the vertebral column) Low-grade intermittent fever Cyanosis Varying degrees of consciousness Hepatomegaly Ascites

14 Differential Diagnosis Angina Pectoris Aortic dissection Aortic stenosis Coronary artery vasospasm Oesphageal ruputure Oesphageal spasm Oesphagitis Acute gastritis GORD Myocardial Infarction Myocardial ischemia Peptic ulcer disease Pulmonary embolism

15 Work up Clinical History Physical examination Initial blood laboratory work CBC, coagulation studies, Serum electrolytes, blood urea nitrogen (BUN) and creatinine levels, ESR, CRP, Cardiac biomarkers Lactate dehydrogenase (LDH) and serum glutamicoxaloacetic transaminase (SGOT; AST) levels Chest X-ray (flask-shaped, enlarged cardiac shadow) smal effusions may not be picked up ECG (can be diagnostic!!) PR-segment depression in 80% in viral pericarditis Echocardiogram Modality of choice for detecting pericardial effusions and diagnosing tamponade. Helpful in confirming diagnosis and particularly if Cardiac Tamponade is suspected

16 Treatment + Management Oxygen and ECG Rule out life-threatening causes (MI or Aortic dissection) Evaluate for evidence of hemodyanamic instability safe to proceed to further investigations? Echo Determine presence or absence of pericardial effusion No effusion suspected viral pericarditis discharged home with follow up care Small to medium effusion Admitted for observation + serial Echo Large effusion stable, urgent pericardiocentesis or pericardial window

17 Complications Recurrence 15-32% Cardiac Tamponade Constrictive Pericarditis Combination of effusive and constrictive pericarditis Noncompressive effusion Cardiac perforation with pericardiocentesis

18 Myocarditis

19 Normal function of the Myocardium The myocardium is the thickest layer of the heart wall and is composed of bundles cardiac muscles cells These cells spontaneously contract to allow the heart to contract and pump blood from the ventricles. Relaxation of these cells allows the filling of the atria producing the heartbeat

20 Myocarditis Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations Most often caused by a viral infection Usually manifests in an otherwise healthy person and can result in rapidly progressive heart failure and arrhythmia

21 Classifications of myocarditis Fulminant myocarditis follows a viral prodrome with a distinct onset of illness of severe cardiovascular compromise and ventricular dysfunction. Acute myocarditis less distinct onset of illness, ventricular dysfunction may progress to dilated cardiomyopathy Chronic active myocarditis less distinct onset of illness, clinical and histological relapses, development of ventricular dysfunction associated with chronic inflammatory changes Chronic persistent myocarditis less distinct onset of illness, persistent histological infiltratebut without ventricular dysfunction despite symptoms (chest pain, palpitations)

22 Pathogenesis of Myocarditis Acute phase Direct infiltration of cardiotrophic virus into myocytes. No histological evidence of myocarditis at this point Sub-acute phase Host attempts to clear virus. Natural killer cells, Macrophages and lymphocytes infiltrate infected heart tissue. Subsequent pro-inflammatory cytokine release, NO production, antibody secretion and upregulation of MHC. Chronic myocarditis Dilated heart with evidence of fibrosis

23 Etiology Caused by a wide variety of infectious organisms, autoimmune disorders and exogenous agents with a genetic and environmental predisposition 50% of myocarditis classified as idiopathic

24 Viral Etiology some causes Enterovirus, Coxsackie B, adenovirus, influenza CMV, poliomyelitis, Epstein-Barr virus Bacterial Diphtheria, TB, streptococci, meningococci Systemic inflammatory disease SLE, Sarcoidosis, UC, Crohns disease, RA Medication Antibiotics, Antihypertensives, Anti-seizure

25 Differential Diagnosis Cardiac Tamponade Cardiogenic Shock Cardiomyopathy Alcoholic Cocanine Dilated Hypertrophic Peripartum Restrictive Chagas Disease Coronary Artery Atherosclerosis

26 Clinical presentation - History Acute decompensation of heart failure but no other underlying cardiac dsyfunction Mild symptoms of chest pain Fever Sweats Chills Dyspnoea In viral myocarditis Patients may present with a history of recent (1-2weeks) flulike syndrome of fever, malaise and athralgias or tonsillitis or URTI Symptoms of palpitations or syncope or even sudden cardiac death may develop due to underlying ventricular arrythmias or atrioventricular block.

27 Clinical Presentation - Examination Acute decompensation of heart failure Tachycardia Gallop (S3+S4 heart sounds) Mitral regurgitation Oedema Concomitant Pericarditis Pericardial friction rub Special findings in special cases depending on cause of myocarditis e.g. Sarcoid myocarditis lymphadenopathy, arrythmias and sarcoid involvement in other

28 Work up Clinical History Physical examination Initial blood laboratory work CBC (leukocytosis), ESR +CRP, RA screening (rule out inflammatory diseases) Elevated cardiac enzymes creatinine kinase and cardiac troponins Serum viral antibody titers (viral myocarditis) Echo Exclude other causes of heart failure Assess degree of cardiac dysfunction ECG often non-specific (patterns mimicking ischemia) Cardiac angiography rule out ischemia, MI Endomyocardial biopsy (EMB) standard of diagnosis of myocarditis

29 Treatment and Management Similar to that of patients with heart failure Supportive therapy for symptoms of acute HF Diurectics, GTN, ACE-inhibitors, Inotropics Long-term treatment ACE-inhibitors, Beta-blockers, Aldosterone receptor antagonists Treat underlying cause systemic inflammatory etiology Surgical Transvenous pacing (complete heart block) Left ventricular assisted devices (LVADs) cardiogenic shock

30 Heart Failure Complications Myocardial Infarction or Stroke Arrhythmias Sudden cardiac death

31 Thank you! Questions?