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Questions and Answers
What is the most common cause of myocarditis worldwide?
Which of the following is NOT a viral cause of myocarditis?
What is the mechanism by which Coxsackie B virus causes autoimmune destruction in myocarditis?
Which of the following systemic diseases is associated with myocarditis?
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What is the treatment for Chagas disease?
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What percentage of HIV patients have myocarditis on autopsy?
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What is the estimated percentage of ED patients presenting with chest pain who will have Benign Early Repolarisation (BER) on their ECG?
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What is the primary use of ancillary tests in diagnosing pericarditis?
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In which age group is Benign Early Repolarisation (BER) least common?
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What is the gold standard for diagnosing pericarditis with effusion?
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What is the primary reason to avoid diagnosing Benign Early Repolarisation (BER) in patients over 50 years?
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What is the recommended treatment for suspected viral pericarditis?
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What is a common clinical feature that suggests a myotropic pathogen?
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What is the role of MRI in diagnosing myocarditis?
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What is the significance of a normal antimyosin scan in a patient with suspected myocarditis?
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What is the gold standard for diagnosing myocarditis?
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What is the primary goal of ED treatment for myocarditis?
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What is the indication for anticoagulation in myocarditis?
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What is the significance of histological changes in myocarditis?
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What is the goal of definitive treatment of myocarditis?
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What is the primary goal of treatment for viral pericarditis?
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What is the minimum amount of fluid required in the pericardium to cause decompensation?
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What is the primary cause of low-pressure tamponade?
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What is the sensitivity of echocardiography in diagnosing pericardial tamponade?
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What is the primary feature of Beck's triad?
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What is the primary indication for pericardiocentesis?
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What is the primary complication of pericardiocentesis?
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What is the primary indication for admission in a patient with viral pericarditis?
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What is the primary cause of traumatic tamponade?
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What is the primary feature of ultrasound in diagnosing pericardial tamponade?
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What is the most common cause of viral pericarditis?
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What is the function of pericardial fluid?
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What is the characteristic of pericardial pain?
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What is the diagnosis of pericarditis in the presence of concomitant pneumonia or empyema?
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What is the treatment of uremic pericarditis?
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What is the characteristic ECG finding in pericarditis?
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What is the stage 2 of pericarditis on ECG?
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What is the complication of pericarditis?
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What is the etiology of pericarditis?
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What is the characteristic of pericardial friction rub?
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Study Notes
Pericarditis and Myocarditis
Pericarditis
- Non-specific inflammation of the pericardium, a rare emergent condition
- Pericardial effusion: accumulation of fluid in the pericardial space, which can be serous, purulent, fibrinous, or hemorrhagic
- Cardiac tamponade: impairment of ventricular filling due to fluid in the pericardial space, an emergent condition
Pericardial Physiology
- Two layers: parietal (thick, collagenous, stiff) and visceral (thin, closely adherent to epicardial surface)
- Pericardial fluid: normally 15-60 cc, prevents friction, prevents infection, augments atrial filling, and maintains normal pressure-volume relationship
- No physiological consequence to absent pericardium
Pericardial Innervation
- Parasympathetic (vagus, left recurrent laryngeal nerve)
- Sympathetic (stellate, first thoracic ganglia)
- Little somatic sensory innervation, resulting in visceral nature of chest pain
Etiology of Pericarditis
- Viral (most common, e.g., enteroviruses, HIV)
- Bacterial (e.g., streptococcus, staphylococcus, gram-negatives, anaerobes, TB, Lyme disease)
- Traumatic
- Malignant (e.g., lung, breast, lymphoma, leukemia, melanoma)
- Post-irradiation
- Post-MI (e.g., Dressler's syndrome)
- Collagen vascular disease (e.g., RA, SLE)
- Drug-induced (e.g., SLE-like syndrome, procainamide, hydralazine, methyldopa, reserpine, doxorubicin)
Viral Pericarditis
- Most common cause of pericarditis
- Mechanism of injury: direct viral cytotoxicity and indirect auto-antibody-mediated effects
- Syndrome may be immediate or develop 2-4 weeks post-viral illness
- Symptoms: chest pain, pericardial friction rub, fever, tachycardia, tachypnea, dyspnea, and diaphoresis
ECG in Pericarditis
- 4 stages of evolution over 3-4 weeks
- Only 50% of patients have all 4 phases
- Stage 1: diffuse ST elevation, PR depression, and reciprocal ST depression
- Stage 2: ECG transiently normal, some T-wave flattening
- Stage 3: T-wave inversion, deep and uniform
- Stage 4: return to normal, some patients with residual T-wave inversion
Management of Pericarditis
- Treat underlying cause
- Colchicine (1-2 mg PO OD) for pain and inflammation
- Steroids (only if NSAID-resistant)
- Admit if cannot rule out MI, pain control, or if effusion suspected
Myocarditis
- Inflammation of the myocardium
- Etiology:
- Viral (most common, e.g., enteroviruses, adenovirus, influenza)
- Bacterial (e.g., S. aureus, streptococcus, mycoplasma, diphtheria)
- Spirochetal (e.g., Lyme disease)
- Mycotic (e.g., candida, aspergillus)
- Rickettsial (e.g., Rocky Mountain Spotted Fever)
- Helminthic (e.g., trichinosis, schistosomiasis)
- Protozoal (e.g., Chagas disease)
- HIV
- Drugs (e.g., cocaine, emetine, doxorubicin, HIV treatment)
- Systemic diseases (e.g., collagen vascular disease, sarcoidosis, Kawasaki's disease)
Pathophysiology of Myocarditis
- Three major mechanisms:
- Myocardial necrosis from direct invasion
- Autoimmune destruction (e.g., beta myosin chain and coxsackie B share 50% same amino acid sequences)
- Endotoxins produced by pathogens
Clinical Features of Myocarditis
- VERY NON-SPECIFIC!
- Tachycardia out of proportion to fever
- Severe myalgias
- Non-anatomical ECG changes
- Continued pain with no ECG evolution
- Global (vs segmental) wall motion abnormalities on echo
- Unexplained CHF or dysrhythmias in previously healthy patient
Diagnosis of Myocarditis
- MRI (contrast-enhanced, shown to be useful, maybe the future?)
- Antimyosin scintigraphy (Indium-111, binds to exposed myosin in damaged myocardium)
- Endomyocardial biopsy (gold standard, Dallas criteria used to standardize diagnosis)
Treatment of Myocarditis
- ED treatment:
- Bed rest
- Cardiac monitoring
- Management of arrhythmias
- CHF treatment (cautious, aggressive preload or afterload reduction may cause cardiogenic shock)
- Anticoagulation (if intracardiac thrombi detected on echo)
- Definitive treatment: treat specific cause if possible (e.g., Chagas disease, Lyme disease)
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Description
Test your knowledge on myocarditis, its causes, mechanisms, and relationships with various diseases. From viral causes to autoimmune destruction and treatment options, assess your understanding of this critical topic.
