Term
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Definition
| endocardium (prevents blood clotting), myocardium (thickest, myocytes, contractility), pericardium (serous pericardium- epicardium/visceral pericardium + parietal pericardium, and fibrous pericardium) (inside->outside). inbetween the visceral and parietal pericardium is a space with a trace amount of serous fluid/pericardial fluid |
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Term
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Definition
| pain not due to coronary artery disease |
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Term
| pericarditis etiology and pathophys |
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Definition
| can be caused by many things- viral infection, bacterial infection including TB, fungal, post infarction (Dressler syndrome)- myocardium w lots of inflammation, can lead to pericardial inflammation as well, post-traumatic pericarditis, iadiopathic, lupus, radiation, metabolic, neoplastic. pathophys: inflammation of pericardium leads to friction and rubbing between layers of serous pericardium -> significant pain, potentially effusion -> significan effusion can lead to impaired ventricular filling, which can depress cardiac output leading to obstructive shock (cardiac tamponade) |
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Term
| pericarditis history and exam |
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Definition
history: recent viral syndrome or other etiology, subacute onset of pleuritic chest pain relieved by leaning forward
exam: friction rub, if hemodynamically significant effusion present: tachycardia/hypotension (oulsus paradoxus), elevated JVP +/- kussmaul's sign, muffled heart sounds |
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Term
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Definition
Labs
¡ Basic metabolic panel (renal function)
¡ CBC (infectious or hematologic process)
¡ TSH, ANA
¡ Troponin/CK-MB (usually negative though can be positive if associated myocarditis)
CXR |
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Term
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Definition
| pericarditis. So with pericarditis alone, you typically would expect a normal chest x-ray. But if you have pericarditis with a significant effusion, you'll see mediastinal widening as you see in this chest x-ray here. |
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Term
| pericarditis ekg findings |
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Definition
Electrocardiogram (EKG)
¡ Diffuse concave-up ST elevation +/- PR depression
¡ PR elevation in aVR
¡ If pericardial effusion present, may see low voltage (sensitive)
or electrical alternans (specific) |
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Term
| pericarditis echocardiogram for? |
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Definition
Echocardiogram (TTE)
¡ Generally performed when pericarditis suspected to rule out wall motion abnormalities (MI) and evaluate for pericardial effusion (both presence and hemodynamic significance) |
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Term
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Definition
| pericarditis ekg. So you can see it's in every lead, but it's most prominent here in lead 2, in lead AVF, and the V5 and V6. You can see this kind of concave-up ST elevation. And in V5 and V6, as well, you can see these VR segments look a little bit depressed with respect to the isoelectric line, which is of course the PT interval. And you don't see anything that's concerning for reciprocal changes as you would see, again, if you were worried about an ST elevation myocardial infarction. |
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Term
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Definition
This is an example of electrical alternans.
And so electrical alternans is basically a cyclic variation of either the amplitude or in some cases even the axis of ventricular depolarization. And basically, what causes this is the heart is swinging within the pericardial sac. And so here, you actually have three rhythm strips down here. In lead 2, for example, you can see it very nicely. Here's a high voltage QRS and here's a low voltage QRS. And that voltage is simply varying because of the heart's changing position as it's swinging throughout.
And actually, here in leads V3 and V4, which are the precordial leads closest to the apex of the heart, which you would expect to have the most movement within the pericardium because the heart is tethered to the pericardium at the base, you actually see a change in axis with every beat. So, again, here at V3 and V4. So this is very concerning for a large effusion. I can't think of anything, frankly, that can cause electrical alterations like this, aside from a large pericardial effusion |
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Term
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Definition
And here is just a still frame clip from an echocardiogram. This is from a sub costal view, so taking a look below the ribs. And as you can see here, the different layers of the heart pointed out. Here's your myocardium. Blood is black on an echocardiogram unless there's a contrast agent used. So here's the right ventricle of the heart, here's the left ventricle of the heart. The blood is black within it. This white lining here is your myocardium. And this white line up here is the pericardium. And normally, those two things should be right next to each other.
And this space here is, like we said before, a potential space. But here you have a very large effusion. Again, fluid is black so this black pocket here is a large effusion within the pericardium |
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Term
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Definition
Treat underlying cause
If viral/idiopathic (most common), NSAIDs first line
Colchicine
Steroids if refractory pain
¡ May increase risk of recurrent pericarditis
If effusion present with signs of tamponade, pericardiocentesis (fluids while waiting) |
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Term
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Definition
Usually good with complete recovery in uncomplicated cases (viral/idiopathic)
May develop recurrent acute pericarditis or chronic constrictive pericarditis requiring pericardiectomy (pericardial stripping) |
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Term
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Definition
Etiology
¡ Viral (including Coxsackie, echovirus, adenovirus, parvovirus, EBV) ¡ Other infectious (bacterial etc)
¡ Autoimmune
¡ Drug-related (hypersensitivity rxn, anthracyclines, cocaine, EtOH) ¡ Metabolic (hyperthyroidism, thiamine deficiency, pregnancy)
¡ Neoplastic (amyloidosis in setting of multiple myeloma)
¡ Idiopathic (>50% of cases) |
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Term
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Definition
Pathophysiology
¡ Inflammation of myocardium leads to heart muscle damage, potentially weakening ability to pump blood (inflammatory cardiomyopathy) |
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Term
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Definition
History
¡ Recent viral syndrome (or another potential etiology)
¡ CHF symptoms (exertional dyspnea, orthopnea, edema) |
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Term
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Definition
¡ Congestive signs
÷ Displaced PMI or S3 ÷ Elevated JVP
÷ Crackles
÷ Peripheral edema
¡ Low flow signs
÷ Tachycardia/Hypotension (esp low pulse pressure) ÷ Cool/clammy extremities or weak/thready pulses ÷ Decreased urine output
÷ Mental status change |
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Term
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Definition
Labs
¡ Basic metabolic panel (renal function)
¡ CBC (infectious or hematologic process) ¡ TSH, ANA, UTox, thiamine level
¡ Troponin/CK-MB
CXR
¡ Cardiomegaly
¡ Pulmonary vascular congestion or frank pulmonary edema |
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Term
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Definition
| myocarditis cxr. So here's a side-by-side comparison of a normal chest x-ray on the left, as opposed to an abnormal heart failure-looking chest x-ray on the right where you see you have cardiomegaly, this cardio mediastinal silhouette is much larger, and then you also see some fluid in the lung spaces as well |
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Term
| myocarditis diagnosis testing |
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Definition
EKG
¡ Nonspecific ST-T changes, diffuse TWI, ST elevation
Echo
¡ Often enlarged heart with decreased systolic function
CMR (cardiac magnetic resonance)
¡ Late gadolinium enhancement (LGE) of myocardium
EMBx (endomyocardial biopsy)
¡ Inflammatory cell infiltration (lymphocytes, eosinophils, etc) |
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Term
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Definition
myocarditis echo. So here are two still clips of echocardiography or heart ultrasound in the peristernal long axis view, which is taken, as the name implies, just next to the sternum on the left side.
And so here closest to the probe is the right ventricle, and then here's your left ventricle. This is a normal heart here. And you can see the left ventricle is sort of bullet-shaped or football-shaped, as opposed to here in this abnormal heart, where the left ventricle is much bigger and rounder and almost looks more like a basketball. And the scale is here on the side with these tick marks. And I tried to make these images somewhat comparable in scale so you can see how much bigger and rounder a heart with a severe cardiomyopathy would appear. |
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Term
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Definition
| myocarditis CMR. And here are some images taken from a cardiac MRI where you can see here, it's the opposite of the echo I showed you. So the blood is white and the myocardium is black. The normal myocardium is black, but here you can see this white line of late gadolinium enhancement. And that's evidence of inflammation or edema or scar. And here you can see it nicely as well. So this normal black myocardium here and this little line here of mid myocardial enhancement. That's very typical for the pattern that we see in myocarditis. |
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Term
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Definition
| myocarditis EMBx. And here are two slides from endomyocardial biopsies of myocarditis. So here you can see a lymphocytic infiltrate, all of these little blue cells here. And it's a little bit less clear in this picture, but you can see an eosinophilic infiltration. Those are some redder cells in this area. |
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Term
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Definition
Treat underlying cause
Supportive treatment
¡ Afterload reduction and inotropes if necessary to improve output ¡ Diuresis to relieve congestion/volume overload
Role for ACEi/ARB
Role for steroids
¡ Eosinophilic myocarditis (drug-related hypersensitivity)
¡ Giant cell (rare, assoc w/chronic infection or autoimmune dz) ¡ Sarcoid (idiopathic systemic granulomatous dz) |
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Term
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Definition
Widely variable based on etiology as well as timing of presentation and treatment
Some patients may have complete recovery
Some remain stable
Some develop worsening heart failure or life- threatening arrythmias (often requiring ICD or advanced heart failure therapy – VAD/txp) |
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Term
| cardiac tamponade pathophys, clinical findings |
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Definition
• Pathophysiology
– Accumulation of fluid in pericardial sac and inability to fill cardiac chambers in diastole lead to reduction of stroke volume and cardiac output
– Leads to hypotension
• Clinical
– Dyspnea on exertion, orthopnea, hepatic engorgement – Hypotension
– JVD (elevation in systemic venous pressure)
– Muffled heart sounds
– Pulsus paradoxus |
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Term
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Definition
• Exaggerated response from the normal physiologic drop in BP with inspiration
• Up to 10 mm Hg drop in systolic BP occurs normally with inspiration
– Tamponade >10 mm Hg drop
• Total paradox complete disappearance of palpable pulse (severe) |
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Term
| cardiac tamponade echocardiogram findings and treatment |
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Definition
• Echocardiogram
– RA and ventricular collapse during diastole
– As little as 15 cc on fluid can be detected by 2D echo
– Differentiate from other causes: tumor compression or hematoma, RV infarct
• Treatment
– Drain the fluid: cath- or echo-guided
– Treat symptoms as for pericarditis
– Pericardiotomy or window placement may be required |
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