Pericarditis, Endocarditis,

Myocarditis
Ns. Irfan Maulana, S.Kep., M.Kep., Sp.KMB
The Pericardium
Two layers - composed of fibrous tissue
inner visceral layer, attached to epicardium
outer parietal layer
stabilizes heart in anatomic position
protects heart - (contact with
surrounding structures)

The Pericardium
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
Presentation & course may vary
depending on the cause
syndromes often associated with
chest pain (pleuritic/postural)
dyspnea
pericardial friction rub (with or w/o
evidence of fluid accumulation or
constriction)
Fever & leukocytosis
Acute Pericarditis
Chest x-ray
may show cardiac enlargement or pleural dx
ECG
generalized ST and T wave changes
characteristic progression (ST elevation, return to
baseline, T wave inversion)
Echocardiogram
often normal in inflammatory pericarditis
may show pericardial effusions
Acute Pericarditis- Causes
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 (Dresslers 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,

effusions that develop slowly, even large ones,
may not produce hemodynamic changes

However .

those that appear rapidly (even small effusions)
can cause tamponade

Acute Pericarditis -
Clinical Features
Tamponade
elevated intrapericardial pressure (>15 mm
Hg), that restricts venous return and
ventricular filling - resulting in decreased
stroke volume /pulse pressure and
increased heart rate/venous pressure
most common complaints;dyspnea and
decreased exercise tolerance
common symptoms; weight loss, pedal
edema, ascites
Acute Pericarditis -
Clinical Features
Tamponade
Physical Findings; tachycardia, low systolic
BP, narrow pulse pressure, pulsus
paradoxus, neck vein distention, distant
heart sounds, RUQ pain

Acute Pericarditis - Diagnosis
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
Most commonly caused by coxsackievirus,
& echovirus
Can also be caused by HIV, influenza,
Epstein-Bar, varicella, hepatitis, mumps
Most commonly affects males < age 50
Diagnosis usually clinical
rising viral titers in paired sera may be
obtained for confirmation of diagnosis
cardiac enzymes may be slightly elevated -
indicating myocarditic component
Viral Pericarditis- Treatment
Generally symptomatic Tx
aspirin or NSAIDs
Corticosteroids -(unresponsive cases)
Symptoms generally subside over several days to
weeks
May be recurrences - during first few weeks - months
Rarely, patients suffer from chronic recurrences
resulting in constrictive pericarditis
Major early complication - tamponade (< 5% of
cases)
Bacterial Pericarditis
staphylococcus, Strep, pneumoniae, B-
hemolytic streptococci, Mycobacterium
tuberculosis
Usually direct result from pulmonary
infection
patients often present in a critically ill state
Borrelia burgdorferi (Lyme Disease
organism) can also cause myopericarditis
Tuberculous Pericarditis
Rare in developed countries - common elsewhere
Results from direct lymphatic or hematogenous
spread
commonly have associated pleural effusions & small
to moderate pericardial effusions
subacute presentation/non-specific symptoms (fever,
night sweats, fatigue)
Diagnosis inferred if acid-fast bacilli found elsewhere
Usual therapy - standard antituberculous drug
Complication- if therapy unsuccessful- constrictive
pericarditis
Uremic Pericarditis
Complication of renal failure
Occurs in untreated uremia and in stable dialysis
patients
Presents with or w/o symptoms, typically afebrile
tamponade is common
usually resolves with institution or more aggressive
dialysis
pericardiectomy may become necessary
indomethacin & systemic glucocorticoids ineffective
for uremic pericarditis
Neoplastic pericarditis
Commonly caused by
breast and renal cell carcinoma, Hodgkin's Disease
and lymphomas
neoplastic processes involving the pericardium
are the most common cause of pericardial
tamponade in many countries
presenting symptoms relate to the
hemodynamic compromise of the primary
disease process
MRI/CT
Neoplastic pericarditis
Prognosis poor - only small minority
survive >year
Effusion can be drained,
chemotherapeutic agents or tetracycline
may prevent recurrence
pericardial windows rarely effective,
partial pericardiectomy from a
subxiphoid incision may be successful
Radiation Pericarditis
Usually occurs within the first year after
exposure but can be delayed for many
years
Symptomatic therapy - initial approach
but recurrent effusions and constriction
require surgery
Post MI or Postcardiotomy
Pericarditis
An inflammatory reaction to transmural
myocardial necrosis that usually occurs
2-5 days after infarction
typically presents as pain recurrence
audible rub, repolarization changes
spontaneous resolution usually occurs
after a few days
Aspirin, NSAIDs -symptomatic relief
Dresslers Syndrome
Occurs weeks to several months after
MI or open heart surgery
Presentation
typical pain, fever, malaise, leukocytosis,
elevated sed rate
large pericardial/pleural effusions common
Tamponade is rare if Dresslers after MI,
but more commonly seen in Dresslers
post-operatively
Dresslers Syndrome
NSAIDs
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
Symptoms develop gradually and mimic
those of restrictive cardiomyopathy
(CHF, exercise dyspnea, decreased
exercise tolerance)
chest pain, orthopnea, and paroxysmal
nocturnal dyspnea are uncommon
Physical Exam
Pedal edema
hepatomegaly
ascites
JVD
Kussmauls 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
General supportive care - initial
treatment
Symptomatic patients - pericardiectomy
Gentle diuresis
Treatment with appropriate antibiotics if
agent is Idd
Endocarditis
Infective endocarditis is defined as an
infection of the endocardial surface of
the heart, which may include one or
more heart valves, the mural
endocardium, or a septal defect

Endocarditis can be broken down into
the following categories:
Native valve (acute and subacute) endocarditis
Prosthetic valve (early and late) endocarditis
Endocarditis related to intravenous drug use

Native valve endocarditis (acute
and subacute)

Native valve acute endocarditis usually
has an aggressive course. Virulent
organisms, such as Staphylococcus
aureus and group B streptococci, are
typically the causative agents of this
type of endocarditis.

Subacute endocarditis usually has a
more indolent course than the acute
form. Alpha-hemolytic streptococci or
enterococci, usually in the setting of
underlying structural valve disease,
typically are the causative agents of this
type of endocarditis.

Prosthetic valve endocarditis
(early and late)

Early prosthetic valve endocarditis
occurs within 60 days of valve
implantation. Staphylococci, gram-
negative bacilli, and Candida species
are the common infecting organisms.

Prosthetic valve endocarditis
(early and late)

Late prosthetic valve endocarditis
occurs 60 days or more after valve
implantation. Staphylococcus
epidermidis, alpha-hemolytic
streptococci, and enterococci are the
common causative organisms.

Endocarditis related to
intravenous drug use

Endocarditis in intravenous drug abusers
commonly involves the tricuspid valve. S
aureus is the most common causative
organism
Infective endocarditis generally occurs as a
consequence of nonbacterial thrombotic
endocarditis, which results from turbulence or
trauma to the endothelial surface of the
heart.


Endocarditis
Increased mortality rates are associated with
increased age, infection involving the aortic
valve, development of congestive heart
failure, central nervous system (CNS)
complications, and underlying disease
Affects men more than women (2:1 ratio)
Affects all age groups - however, 50% of
cases in adults over age 50

Endocarditis
Most common symptoms - fever (90% of
cases) and chills
Anorexia, weight loss, malaise, headache,
myalgias, night sweats, shortness of breath,
cough, or joint pains are common complaints
Dyspnea, cough, and chest pain are common
complaints of intravenous drug users who
have infective endocarditis


Endocarditis
Primary cardiac disease may present
with signs of congestive heart failure
due to valvular insufficiency
Heart murmurs are heard in
approximately 85% of patients
Endocarditis
One or more classic signs of infective endocarditis are found
in as many as 50% of patients. They include the following:
Petechiae - Common but nonspecific finding
Splinter hemorrhages - Dark red linear lesions in the
nailbeds
Osler nodes - Tender subcutaneous nodules usually
found on the distal pads of the digits
Janeway lesions - Nontender maculae on the palms and
soles
Roth spots - Retinal hemorrhages with small, clear
centers; rare and observed in only 5% of patients.

splinter hemorrhages and purpuric
papules on the foot of a 10 year old
boy with acute bacterial endocarditis
Splinter hemorrhages(Panel A) are normally seen under the fingernails.
They are usually linear and red for the first two to three days and brownish
thereafter.
Panel B shows conjunctival petechiae.
Osler's nodes (Panel C)are tender, subcutaneous nodules, often in the pulp
of the digits or the thenar eminence.
Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or
pustular lesions, often on the palms or soles

Endocarditis
baseline studies, such as a complete blood count
(CBC), electrolytes, creatinine, BUN, glucose, and
coagulation panel
Blood cultures: Two sets of cultures have >90%
sensitivity when bacteremia is present. Three sets
of cultures improve sensitivity and may be useful
when antibiotics have been administered previously

Endocarditis
Echocardiogram
Transthoracic echocardiography has a sensitivity
of approximately 60%. Transesophageal
echocardiography has a sensitivity of more than
90% for valvular lesions

Endocarditis
Empiric antibiotic therapy is chosen
based on the most likely infecting
organisms. Native valve disease usually
is treated with penicillin G and
gentamicin for synergistic treatment of
streptococci

Endocarditis
Patients with a history of IV drug use
may be treated with nafcillin and
gentamicin to cover for methicillin-
sensitive staphylococci.

Endocarditis
Infection of a prosthetic valve may
include methicillin-resistant
Staphylococcus aureus; thus,
vancomycin and gentamicin may be
used, despite the risk of renal
insufficiency

Endocarditis
Rifampin also may be helpful in patients
with prosthetic valves or other foreign
bodies; however, it should be used in
addition to vancomycin or gentamicin.


Endocarditis
prophylaxis against infective endocarditis in patients
at higher risk. Patients at higher risk include those
with the following conditions:
Presence of prosthetic heart valve
History of endocarditis
History of rheumatic heart disease
Congenital heart disease with a high-pressure
gradient lesion
Mitral valve prolapse with a heart murmur

Endocarditis
prophylaxis in patients before they undergo
procedures that may cause transient bacteremia,
such as the following:
Ear, nose, and throat (ENT) procedures
associated with bleeding, including dental
manipulations and nasal packing
Incision and drainage of an abscess
Anoscopy and Foley catheter placement when a
urinary tract infection is present or suspected





Myocarditis
Myocarditis
Inflammation of the myocardium
May be the result of systemic disorder
or infectious agent ...usually follows an
upper resp infection
Pericarditis frequently accompanies
myocarditis
Drug induced, cytotoxic agents,also,
cocaine
Myocarditis
Bacterial cases include;
Corynebacterium diphtheriae, Neisseria
meningitides, Mycoplasma pneumoniae,
and B-hemolytic streptococci
Viral etiologies include;
coxsackie B, echovirus, influenza,
parainfluenza, Epstein-Barr, and HIV
Myocarditis -clinical features
Systemic signs/symptoms (fever,
tachycardia, myalgias, headache, and
rigors)
chest pain due to coexisting pericarditis
pericardial friction rub in cases of
concomitant pericarditis
In severe cases - symptoms of
progressive heart failure (CHF,
pulmonary rales, pedal edema, etc.)
Diagnosis
Nonspecific ECG changes,
atrioventricular block, prolonged QRS
duration, or ST segment elevation (in
cases of accompanying pericarditis)
normal chest x-ray
cardiac enzymes may be elevated
Differential diagnosis includes cardiac
ischemia or infarction, valvular disease
and sepsis
Treatment
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 ?