Traumatic-Infectious & Inflammatory Heart Conditions

What does this refer to

• Effusion present when accumulated fluid within pericardial sac exceeds small amount that is normally present

• Acute or chronic

• Hemodynamically stable - unstable

Pericardial effusion

What does this refer to

• Small effusions are often asymptomatic

• Found in 3% of subjects in autopsy studies

• Observed in all age groups

  • Mean occurrence 30-49yo

• Mortality/morbidity dependent on etiology/comorbid conditions

• M = F

EpidemiologyPericardial Effusion

What does this refer to

• Effusion present when accumulated fluid within pericardial sac exceeds small amount that is normally present

• Acute or chronic

• Hemodynamically stable - unstable

Pericardial effusion

What does this refer to

• Small effusions are often asymptomatic

• Found in 3% of subjects in autopsy studies

• Observed in all age groups

  • Mean occurrence 30-49yo

• Mortality/morbidity dependent on etiology/comorbid conditions

• M = F

EpidemiologyPericardial Effusion

What does this refer to

• Can occur as a component of almost any pericardial disorder

• Acute pericarditis

  • Viral

    • Enteroviruses: coxsackie, enterovirus and echoviruses

• Autoimmune disease/Neoplastic disease

• Postmyocardial infarction or cardiac surgery

  • Dressler’s syndrome

• Sharp or blunt chest trauma

• Drugs (procainamide, hydralazine, isoniazid)

EtiologyPericardial Effusion

What does this refer to

• Will have no symptoms specific to effusion

• May have symptoms of underlying cause

Clinical history-hemodynamically stablePericardial Effusion (Patients WITHOUT hemodynamically significant effusion)

What does this refer to

• Fatigue

• Dyspnea

• Elevated jugular venous pressure

• Edema

• Chest pain, pressure, discomfort

  • Improved by sitting up/leaning forward

  • Intensified by lying supine

Clinical history-hemodynamically unstablePericardial Effusion (progressing to cardiac tamponade)

What does this refer to

• Pulsus paradoxus

  • Decrease in systolic blood pressure of more than 10mm Hg with inspiration

• Friction rub left lower sternal border

• Tachycardia/Tachypnea

  • Muffled heart tones

• Ewart sign

  • Dullness to percussion beneath angle of left scapula

• Extremities

  • Weak peripheral pulses

  • Edema

  • Cyanosis

Physical examPericardial Effusion

What does this refer to

• Place a blood pressure cuff on patient’s arm

• Very slowly deflate cuff while listening for Korotkoff sounds

• Note pressure you first hear sounds during expiration

• Repeat process and record pressure where sounds are heard during inspiration

• Difference between the two numbers is pulsus paradoxus

Physical exampulsus paradoxus - Pericardial Effusion

What does this refer to

• Acute Pericarditis

• Cardiac Tamponade

• Dilated Cardiomyopathy

• Acute MI

• Pulmonary Embolism

Differential diagnosisPericardial Effusion

What does this refer to

Workup for Pericardial effusion

What does this refer to

• Confirming presence of a pericardial effusion

• Assessing any hemodynamic impact

• Establish cause if possible

• Echocardiography*

  • Imaging modality of choice for diagnosis*

How Pericardial Effusion is diagnosed

What does this refer to

• Findings are variable, depending on etiology and size of effusion

  • *Not specific and or diagnostic

• < 250 mL may not result in significant findings

• Larger effusions present with an enlarged cardiac silhouette/clear lung fields

• **Water bottle–shaped heart*

CXR Pericardial Effusion

What does this refer to

• Early pericardial effusion

  • ECG typically displays diffuse ST elevation*

• Triad

  • Low QRS voltage

  • Tachycardia

  • Electrical alternans

EKG Pericardial Effusion

What does this refer to

• Consultations

  • Cardiologist/Cardiothoracic surgery

• Medical care

  • Focused to determine etiology

  • Treatment of underlying disease(s)

Clinical managementPericardial Effusion

What does this refer to

Pericardial fluid drainage

• Indications for urgent drainage depend on level of hemodynamic compromise

• Choice of pericardiocentesis/open drainage based on local preference and experience

Clinical interventionpericardiocentesis – Pericardial Effusion

What does this refer to

• HIV/AIDS, cancer or otherwise immunocompromised —> high mortality rates

• Complications

  • Ventricular rupture

  • Dysrhythmias

  • Pneumothorax

  • Myocardial injury

  • Infection

• Recurrence may be 90% in cancer patients

• May progress to cardiac tamponade

PrognosisPericardial Effusion

What does this refer to

• ________ : Compression of the heart by an accumlation of fluid in the pericardial sac

• A clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise.

• Is a medical emergency, the complications of which include pulmonary edema, shock, and death.

Cardiac tamponade

What does this refer to

• Pericardial effusion that causes accumulation of enough fluid to compress the heart enough to cause cardiac function impairment

• Results in a stiffening of the pericardium if not corrected

• Classification

  • Acute

  • Subacute

Cardiac tamponade

What does this refer to

• Approximately 2 cases/10,000 in US

  • 2% of penetrating trauma cases have cardiac tamponade

• M > F [1.5 : 1]

• Traumatic and infectious sources more common in younger people

• Uremic and Neoplastic more common in older populations

EpidemiologyCardiac Tamponade

What does this refer to

• Rate of fluid accumulation is very important

  • Rapid

  • Slow

• Can occur as a result of any process that causes pericarditis

• Malignant Effusion

• Penetrating trauma

• Uremia

• Thoracic Aortic Dissection

• Infectious disease

• Inflammatory process

• Ventricular rupture

EtiologyCardiac Tamponade

What does this refer to

• Pericarditis of any etiology

• Active Cancer

• Penetrating Trauma

• Acute Renal Failure/Uremia

• Tuberculosis infection

• Systemic Autoimmune Disease

• History of HIV/IV drug abuse

• H/O chest radiation

• Recent pacemaker/AICD implantation or other recent cardiac surgery

• Recent MI

Risk factorsCardiac Tamponade

What does this refer to

• Chest Pain

• Dyspnea/tachypnea

• Cough

• Pulsus paradoxus

Clinical historyCardiac Tamponade

What does this refer to

• _________ is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration.

Pulsus paradoxus

What does this refer to

Physical examCardiac Tamponade

What does this refer to

1. Hypotension

2. Jugular venous distension

3. Muffled heart sounds

Beck’s Triad (cardiac tamponade)

What does this refer to

• Pericarditis/Myocarditis

• Acute Coronary Syndrome (ACS)

• Pneumothorax

• Pulmonary Embolism

• Pleural Effusion

• Thoracic Aortic Dissection

• Hemopericardium

Differential Diagnosis of Cardiac tamponade

What does this refer to

WorkupCardiac Tamponade

What does this refer to

ECG is poorly diagnostic of pericardial effusion and cardiac tamponade.

What does this refer to

How’s it diagnosed?Cardiac Tamponade (Echo)

What does this refer to

2D echocardiography that shows dilation of the IVC (>20 mm in an adult size heart) and hepatic veins, known as IVC plethora, not specific but a sensitive sign of cardiac tamponade)

What does this refer to

• Mechanical drainage/removal of fluid

  • ER treatment

    • Pericardiocentesis 1st line

  • Open drainage

  • Pericardial window (recurrent)

• Need for Intubation

  • Ventilatory support

• IV Fluid (IVF) bolus 500-1000mL

  • Be aware of adverse effects to include pulmonary edema/↓ cardiac output

Clinical interventionCardiac Tamponade

What does this refer to

• IV Fluid (IVF)

  • Bolus 500-1000mL

• Vasopressors

  • If needed

  • Not contraindicated

Clinical managementCardiac Tamponade

What does this refer to

• Outcome associated with etiology of cardiac tamponade and pre-existing comorbidities

• Mortality

  • 1-year mortality rate 77% for malignant effusion

  • 13% mortality rate for non-malignant effusion

PrognosisCardiac Tamponade

What does this refer to

• Pregnancy category: C

• Lactation: Drug does not enter breast milk; use with caution because of potential vitamin loss in mother

Cholestyramine

What does this refer to

• “: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.”

Pregnancy category A

What does this refer to

• “May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk”

Pregnancy category B

What does this refer to

• “Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done”

Pregnancy category C

What does this refer to

• “Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.”

Pregnancy category D

What does this refer to

• “Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.”

Pregnancy category X

What does this refer to

• “: Information not available”

Pregnancy category N/A

What does this refer to

• _____________ are used to treat hyperlipidemia (HLD) in pregnancy

Bile Acid Sequestrants

Bile acid sequestrants increase the risk of developing _________ so they should not be used to treat HLD in patients who are already at risk or who have osteopenia/osteoporosis

osteoporosis

Can you use statins in pregnancy?

Can you use ezetimibe in pregnancy?

No it is category C and a contraindication

Can you use ezetimibe + statin in patients with osteopenia or osteoporosis?

• Yes, there is no contraindications

• There does not seem to be a “protective” feature to prevent or reduce risk of developing osteopenia/osteoporosis

What does this refer to

• Infection in the heart valves or endocardium

Infective Endocarditis

Is this acute or subacute bacterial endocarditis?

Acute

Is this acute or subacute bacterial endocarditis?

Subacute

What does this refer to

• M > F

• No racial predilection

• Prevalence > 60 yo

• Dx at younger age often related to IV drug abuse (IVDA)

EpidemiologyInfective Endocarditis

What does this refer to

EtiologyInfective Endocarditis

What does this refer to

• Native valve endocarditis

  • S. aureus and streptococcal species account for majority of cases

  • Fungi account for a small percentage (MC IVDA)

• S. aureus most common cause among injection drug users

  • Prosthetic valve endocarditis

    • Early disease MC caused by S. epidermis

  • Enterococci

    • Recent GU or GI infection

PathogensInfective Endocarditis

What does this refer to

• 2/3 of patients have no prior hx of heart disease or murmur

• Murmur may be absent with tricuspid valve involvement

• MC pathogen is MRSA

• Present with pleuritic chest pain

Etiology with ivdaInfective Endocarditis

What does this refer to

• IV drug use/abuse (IVDA)

• Poor dentition or dental infection

• Structural (valvular) heart disease

• History of infective endocarditis

• Hemodialysis

• HIV infection

Risk factorsInfective Endocarditis

What does this refer to

Endocarditis

What does this refer to

• Valve replacement

  • Refractory CHF

  • Persistent infection

  • Invasive infection

  • Previous prosthetic valve

  • Recurrent systemic emboli

  • Fungal infections

Surgical (operative) intervention for infective endocarditis

What is the non-operative management of native valve endocarditis (NVE) —> 4-6 weeks (clinical pharmcotherapeutics empiric therapy, infective endocarditis)

• Ceftriaxone OR Gentamicin

• MRSA or PCN allergy —> vancomycin

What is the non-operative management of Prosthetic valve endocarditis (PVE) —> 4-6 weeks (clinical pharmcotherapeutics empiric therapy, infective endocarditis)

Vancomycin + Gentamicin + Rifampin

What is the non-operative management of critically ill/unstable (clinical pharmcotherapeutics empiric therapy, infective endocarditis)

• Vancomycin + cefepime + piperacillin-tazobactam

• Suspect pseudomonas a

What is the non-operative management of fungal endocarditis (clinical pharmcotherapeutics empiric therapy, infective endocarditis)

• Amphotericin B (6-8 weeks)

• Surgical intervention often needed with fungal pathogens

What does this refer to

Infective Endocarditis Prophylaxis prevention

What does this refer to

• Largely dependent on whether or not complications resulted from the infection

• Best cure rates by organism

  • Strep viridans and strep bovis —> 98%

  • Enteroccoci and s. aureus (IVDA) 90%

  • Non-IVDA community acquired S. aureus 60-70%

  • Aerobic gram-negative organisms 40-60%

  • Fungal organisms < 50%

• Complications include HF, new valve disease, conduction abnormalities, cerebral embolism, renal embolism and/or infarct

• Untreated almost always fatal

Prognosis of infective endocarditis

What does this refer to (*on test)

Infective Endocarditis

What does this refer to

Infective Endocarditis

What does this refer to

Mechanical ______

• Limiting acute dilation

• Maintaining ventricular compliance

• Distributing hydrostatic forces

Membranous ________

• Reduces external friction

• Barrier against infection and malignancy

Ligamentous ______

• Anatomically fixes heart

Function of the pericardium

What does this refer to

• Inflammation of pericardium characterized by

  • Chest pain

  • Pericardial friction rub

  • Serial electrocardiographic changes

Acute pericarditis

What does this refer to

• Uremic etiology common in patients with advanced renal disease (before dialysis)

• Malignant disease is the most common cause of pericardial effusion with tamponade in developed countries

• M > F

• More common in men under age 50

• More common in adults than children

Epidemiology of acute pericarditis

What does this refer to

• MC cause in immunocompetent patients —> post-viral infection or idiopathic (80%)

• Uremic pericarditis is a common complication associated with chronic renal failure

• Inflammatory disorders

  • RA, SLE, Rheumatic fever

• Cardiovascular

  • AMI

  • Dressler syndrome = post MI + fever + pleural effusion

  • Aortic dissection

• Metabolic disorders

• Neoplasms, drugs, trauma

Etiology of acute pericarditis

What does this refer to

• Presentation depends on underlying etiology

• Major clinical manifestations

  • Acute onset chest pain

    • Substernal and may radiate to neck/shoulders

    • Typically pleuritic

    • Improved by sitting up and leaning forward

Clinical history of acute pericarditis

What does this refer to

Physical exam of acute pericarditis

What does this refer to

• Two of the following four criteria:

  • 1. Non-ischemic chest pain

  • 2. ECG evidence of PR depression or ST segment deviation

  • 3. Detection of a pericardial rub on auscultation

  • 4. Pericardial effusion on 2-D echocardiography (best INITIAL test)

• BEST TEST – T2 Weighted Cardiac MRI (does NOT require contrast)

  • Make the “best test” better by using gadolinium contrast

Diagnostic criteria

What does this refer to

• Diagnosis suspected

  • Pleuritic chest pain, and confirmed if a pericardial friction rub

  • Persistent fever and pericardial effusion or new unexplained cardiomegaly

• Angina Pectoris/Myocardial Infarction

• Aortic Dissection

• Esophageal Rupture

• Gastroesophageal Reflux Disease

• Pulmonary Embolism

Differential Diagnosis of Acute Pericarditis

What does this refer to

Workup Acute Pericarditis

What does this refer to

Diffuse ST segment elevations seen in leads II, aVF, V2 to V6

• Diffuse ST elevation at onset of acute pain is a hallmark of acute pericarditis

• Workup stage 1 EKG acute pericarditis

What does this refer to

(Workup - subsequent ekg changesAcute Pericarditis)

Stage 2

• ST segment returns to baseline in a few days

Stage 3

• T waves become inverted

Stage 4

• Returns to baseline in weeks to months

What does this refer to

EKG workup for acute pericarditis

What does this refer to

Workup - EKG stage II acute pericarditis

What does this refer to

Workup stage 4 ekg (atypical) - acute pericarditis

What does this refer to

• Echocardiogram

  • Often normal

  • Essential for evaluation of pericardial effusion

• CT scan

  • Provides details of entire pericardium

  • Normal thickness by CT is < 2 mm

  • Thickening suggestive of acute pericarditis

• MRI

  • Provides details without contrast or radiation

Imaging Acute Pericarditis

What does this refer to

• Cardiology consultation

• Surgical intervention

  • Pericardiectomy (best for constrictive pericarditis)

  • Pericardiocentesis (effusions > 250mL)

  • Pericardial window placement

  • Pericardiotomy (refractory cases)

Clinical intervention of acute pericarditis

What does this refer to

Clinical pharmacotherapeutics of acute pericarditis

What does this refer to

• Depends on etiology

• Idiopathic and viral etiologies usually have a self-limited course

• Most post–MI cases have a benign course

• With 1st occurrence co-existing pleural effusion is common

Prognosis of acute pericarditis

What does this refer to

• Long term/chronic inflammation of the pericardium

  • Thickening and scarring

• Restriction of ventricular diastolic filling

Constrictive Pericarditis

What does this refer to

• Effects those with conditions related to the Etiology

EpidemiologyConstrictive Pericarditis

What does this refer to

• Occurs due to things that cause inflammation to develop around the heart

  • Heart Surgery

  • Radiation therapy to the chest

  • Tuberculosis

• Any cause of acute pericarditis can cause constrictive pericarditis

EtiologyConstrictive Pericarditis

What does this refer to

• Dyspnea that develops slowly and gets worse (MC sx)

• Fatigue

• Orthopnea

• Chronic edema of the legs and ankles

• Ascites

• General weakness

Clinical history constrictive pericarditis

What does this refer to

• Fever

• Tachycardia

• Palpitations

• Paroxysmal nocturnal dyspnea

• Diaphoresis

• Heart tones

  • “Pericardial knock”

Physical exam constrictive pericarditis

What does this refer to

• Restrictive Cardiomyopathy

• CHF

• Valvular disease

• Atherosclerotic disease

  • Fatty deposits in vessels

• Cardiac Tamponade

Differential Diagnosis of constrictive pericarditis

What does this refer to

Workup constrictive pericarditis

What does this refer to

• generalized T wave flattening or inversion, with normal QRS

Constrictive pericarditis ECG

What does this refer to

• Pericardial calcification (lateral)

• Lung fields clear

Workup CXR constrictive pericarditis

What does this refer to

• Pericardial thickening/calcification

• Exclude restrictive cardiomyopathy

Workup – EchoConstrictive Pericarditis

What does this refer to

• Invasive hemodynamic procedure

• Direct measurement of right-sided cardiac pressures and calculation of cardiac output.

Right heart cath (workup heart catheterization, differentiate right and left heart cath)

What does this refer to

• Diagnostic and therapeutic

• Assess cardiac hemodynamics and valvular lesions

• Main diagnostic role is the assessment of coronary artery disease

Left heart cath (workup heart catheterization, differentiate right and left heart cath)

What does this refer to

• Square root sign

Workup – Right heart cathConstrictive Pericarditis

What does this refer to

• Improve heart function → treat underlying etiology

• Diuretics

  • Loop or thiazides

  • Aldosterone antagonists

• Low Sodium diet

• Indication for surgical pericardiectomy

  • Refractory to medical management

  • Involves cutting or removing the scarring and part of the sac-like covering of the heart

Clinical management constrictive pericarditis

What does this refer to

• Must be treated to avoid complications and exacerbations

• Mortality rate as high as 15% if pericardiectomy needed

• Predictors of poor prognosis

  • Prior radiation

  • Renal disease

  • High pulmonary systolic pressures

  • Abnormal LV systolic fxn

  • Advanced age

Prognosis constrictive pericarditis

What does this refer to

• A 26-year-old man presents to his primary care physician due to shortness of breath and mild palpitations.

• He reports that his symptoms have progressively worsened over the course of a month.

• His shortness of breath is most apparent with climbing the stairs or low-intensity jogging.

• Approximately 2 months ago, he experienced an upper respiratory infection.

• Physical examination is unremarkable.

• An electrocardiogram demonstrates nonspecific cardiac abnormalities and cardiac biomarkers and chest radiograph are unremarkable. Preparations are made to obtain a cardiac echocardiogram.

Myocarditis

What does this refer to

• Inflammatory disease of the myocardium

• Wide range of Physical Exams (subtle to devastating)

• 2 stages of myocardial damage

  • Acute

  • Chronic

Myocarditis

What does this refer to

• Equal among races

• M = F

• Susceptible populations

  • Immunocompromised

  • Pregnant women

  • Children (esp neonates)

Epidemiology of myocarditis

What does this refer to

Etiology of Myocarditis

What does this refer to

• Myocyte destruction

• Results in cytotoxicity and cytokine release

• Furthers myocardial damage

• Detection of causal agent in this stage is rare

Acute (first 2 weeks) stages of myocardial damage (myocarditis)

What does this refer to

• Continuing myocyte destruction is autoimmune

• Abnormal expression of HLA in myocytes

Chronic (> 2 weeks) stages of myocardial damage (myocarditis)