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Myocarditis
• Can be
– a primary site of disease
– involved in other disease processes that
affect the heart
– affected by other diseases of adjacent
tissue
The pericardium can permit moderate
changes in cardiac size, however, it cannot
stretch rapidly enough to accommodate
rapid dilation of the heart or accumulation
of fluid w/o increasing
intrapericardial/intracardiac pressure
Acute Pericarditis
• Acute inflammation of the pericardium
• Origin
– infectious,systemic diseases,malignancy,
radiation,drug toxicity,hemopericardium,other
inflammatory processes in the myocardium or lung
• Pathologic process often involves both the
pericardium and the myocardium
Acute Pericarditis
• viral infection
– most common coxsackievirus, & echovirus
• also- HIV,influenza,Epstein-Bar, varicella,
hepatitis, mumps
• bacterial infection
– staphylococcus, Strep pneumoniae, B-
hemolytic streptococci, Mycobacterium
tuberculosis, lyme dz
• Fungal infection
• Malignancy
Acute Pericarditis - Causes
• Drugs
– procainamide,hydralazine,minoxidil
• radiation
• connective tissue disease(lupus,rheum)
• uremia
• myxedema
• post-MI (Dressler’s syndrome)
• Idiopathic
Acute Pericarditis -
Clinical Features
• Sudden or gradual onset of sharp or
stabbing chest pain that radiates to the
back, neck, left shoulder, arm, or
trapezial ridge
• Pain aggravated by movement or
inspiration and by lying supine
• sitting up and leaning forward reduces
the pain
Acute Pericarditis -
Clinical Features
• Associated symptoms include;
– low grade intermittent fever, dyspnea,
dysphagia
• transient, intermittent friction rub heard
best at the lower left sternal border or
apex is the most common physical
finding
Acute Pericarditis -
Clinical Features
• Pericardial effusion
– As the pericardium stretches,
• However ….
• ST-segment elevation
• Pericarditis w/o other underlying cardiac
disease does not typically produce
dysrhythmias
• Chest x-ray usually normal - but should
be done to rule out other disease
• Echocardiography
Acute Pericarditis - Diagnosis
• Other Tests
– CBC w/diff
– BUN
– Creatinine
– streptococcal serology
– appropriate vial serology
– other serology (antinuclear and anti-DNA
antibodies)
– thyroid function studies
– Sed rate, creatinine kinase levels
w/isoenzymes
Viral Pericarditis
• NSAID’s
• Corticosteroids
• Recurrences common
Constrictive Pericarditis
Constriction occurs when fibrous
thickening and loss of elasticity of
the pericardium results in
interference of diastolic filling
usually following inflammation
Cardiac trauma, open heart
surgery, intrapericardial
hemorrhage, fungal or bacterial
pericarditis, and uremic pericarditis
are the most common causes of
constrictive pericarditis (in the past,
tuberculosis was also included)
Constrictive Pericarditis - symptoms
• Pedal edema
• hepatomegaly
• ascites
• JVD
• Kussmaul’s sign(^jvp w/insp)
• pericardial knock (early diastolic sound)
heard at the apex
• usually - no friction rub
Diagnosis
• ECG - may show low voltage QRS complexes
and inverted T waves
• Chest x-ray - 50% of cases show pericardial
calcification
• Doppler echocardiography
• Cardiac CT, MRI
• Consider other diseases - acute pericarditis,
myocarditis, exacerbation of chronic ventricular
dysfunction, or systemic process (eg sepsis)
Treatment
Echocardiogram
Transthoracic echocardiography has a sensitivity
of approximately 60%. Transesophageal
echocardiography has a sensitivity of more than
90% for valvular lesions
Endocarditis
• Supportive care
• If bacterial cause suspected, antibiotics
are appropriate
• Myocardial biopsy may reveal
inflammatory pattern
• Many cases spontaneously resolve
others progress to dilated
cardiomyopathy
Questions ?