Acute Pericarditis ECG conference

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Acute Pericarditis/ECG conference

• Jimmy Klemis, MD
• Jan 8, 2002

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Pericardium

• Visceral / serous
• Direct contact with epicardium (ST elev)
• single layer mesothelial cells
• Parietal / fibrous
• mesothelial and fibrous layer

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Pericardial Anatomy
Visceral transparent Parietal
translucent Transverse sinus curved probe
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Etiology Acute Pericarditis

• Infectious
• Viral Coxsackie, Echo, EBV, Influenza, HIV
• Bacterial TB, staph, hemophillus, pneumococcal,
  salmonella
• Fungal/other histo/blasto/coccidio, rickettsia
• Rheumatologic
• SLE, Sarcoid, RA, Dermatomyositis, Ankylosing
  Spondylitis, Scleroderma, PAN
• Neoplastic
• Primary angiosarcoma, mesothelioma
• Metastatic breast, lung, lymphoma, melanoma,
  leukemia
• Immunologic
• Celiac sprue, Inflammatory Bowel Disease
• Drug
• Hydralizine, Procainamide
• Other
• MI, Dresslers, Post Pericardiotomy, Chest
  Trauma, Aortic dissection
• Uremic, Post Radiation
• IDIOPATHIC

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Acute Pericarditis Clinical

• History
• preceding viral illness, etc
• Symptoms
• Chest pain
• Signs
• Friction Rub
• ECG
• early PR / ST changes
• late isoelectric ST/ T inv

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History

• Often preceding viral illness 1-2wk prior
• Chest Pain
• Sudden, sharp,pleuritic, constant
• worse supine/ L lat decub, relief sitting up
• radiation back, trapezius ridge
• symptoms usually resolve by 2 weeks, ECG
  abnormalities may persist for months

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Auscultory Rub(s)

• Endopericardial (classic)
• triphasic atrial sys, ventricular sys, early
  diastole
• may only hear 2 phase (afib or tachycardia) or 1
• loudest LSB, raised extremities/increased venous
  return
• Pleuropericardial
• exopericardial, extension into adjacent
  structures
• marked resp variation, musical quality
• Conus
• dilation of pulm conus in hyperactive heart
• PE, thyroid storm, acute beriberi
• Pneumohydropericardium
• air/gas overlying pcard fluid
• metallic tinkle (small amt) churning/splashing
  mill-wheel sound (lg)

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ECG

• PR depression
• ST elevation
• concave up, ST/T V6 gt.25, no reciprocal
• DDx
• Acute MI
• Early Repolarization
• Myocarditis
• Aneurysm
• other Brugada, BBB

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ECG
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Acute Pericarditis - Stages

• Stage I
• first few days ? 2 weeks
• ST elev, PR depression
• up to 50 of pt with sxs/rub do NOT have/evolve
  stage I1
• Stage II
• last days ? weeks
• ST returns to baseline, flat T
• Stage III
• after 2-3 weeks, lasts several weeks
• T wave inversion
• Stage IV
• lasts up to several months
• gradual resolution of T wave changes

1 Spodick DH, Pericardial Disease. Braunwauld 6th
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Acute PCARD Stage I, II
60 y/o man with acute PCARD on presentation and
after 1 mo resolution of sxs, Marriotts
Practical ECG 10th ed, p 208
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Acute PCARD Stage III
19 y/o Female after 1 wk in hospital with Acute
Pericarditis
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DDx PCARD vs Repol
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DDx PCARD vs MI
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Cardiac Isoenzymes - ? helpful

• 2 year study, ER based1
• 14 pt with 2/3 findings (CP typical for PCARD,
  rub, and ECG changes c/w PCARD)
• 71 had elevated TropI (pk 21) with negative CAD
  workup
• Not reliable to differentiate MI vs PCARD

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

• NSAIDS/ASA
• ASA 650 q3-4hr
• Ibuprofen 300-600 q 6-8 hrs x 1-4days
• Avoid Indocin, reduces CBF
• Steroids
• if no response after 48hr NSAID
• use concurrent NSAID
• Colchicine
• .6 q12 chronic /- NSAID
• useful in recurrent pericarditis
• symptom free period 3.1 /- 3mos vs 43 /- 35mos
  (plt.00001)
• in largest multicenter trial to date1
• Anecdotal evidence of benefit in Acute PCARD,
  effusion

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

• Pericardial Effusion/Tamponade
• Constrictive Pericarditis
• can be transient 10 may have transient sxs
  within 1st month, resolves by 3 months
• Recurrent Pericarditis (20-25)
• Rx NSAIDS/Colchicine /- steroids

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Gross Pathology
Bread Butter appearance
Fibrinous stranding
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Acute PCARD Stage I
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ECG Quiz
Acute Pericarditis, Stage I
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ECG quiz 2
Acute Ant MI
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ECG quiz 3
Early Repolarization
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ECG quiz 4
Early Repolarization
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ECG Quiz 5
Pericardial dz, diffuse ST elev
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ECG Quiz 6
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ECG Quiz 6a
Acute antseptal MI
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ECG Quiz 7
Early Repolarization
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ECG quiz 8
Incomplete RBBB