Pericarditis: Post-MI vs. Acute Viral

Post-MI Pericarditis

• Also known as Dressler's syndrome
• An autoimmune response after a myocardial infarction (MI)
• Presents with sharp chest pain that improves when sitting up
• Other clinical signs include fever, pericardial friction rub, and leukocytosis
• Typically appears days to weeks post-MI

Acute Viral Pericarditis

• Presents as sharp, pleuritic chest pain, which is relieved by leaning forward
• This pain is worsened by lying flat or deep breathing
• Pain may radiate to the trapezius ridge
• A scratchy pericardial friction rub is best heart at the Lower Sternal Border (LSB)
• Often follows a recent viral illness
• Pain can be retrosternal or left precordial, radiating to trapezius ridge
• Viral etiology is most common

Outcomes of Acute Pericarditis

• Most cases resolve completely, especially if the cause is viral or idiopathic
• Using colchicine + NSAIDs reduces the risk of recurrence
• Acute pericarditis can become chronic or recurrent
• It may progress to constrictive pericarditis
• Effusion may be associated with acute pericarditis
• Acute pericarditis may develop into constrictive pericarditis

ECG Findings in Acute Pericarditis

• Diffuse ST elevations (concave upward) are usually present in all leads
• Excludes aVR and V1
• PR-segment depression (and/or PR elevation in lead aVR) may be present
• Days later, ST returns to baseline and T-wave inversion develops
• Atrial premature beats and atrial fibrillation (AF) are common

Diagnosis and Treatment of Acute Viral Pericarditis

• Diagnosis includes:
  • History and physical exam (sharp chest pain, pericardial rub)
  • EKG (diffuse ST elevation, PR depression)
  • Echo to assess for effusion
  • Exclusion of MI (normal troponins unless myopericarditis)
• Treatment includes:
  • NSAIDs + colchicine
  • Aspirin
  • Steroids (reserved for autoimmune or refractory cases)
  • Avoid anticoagulants

Constrictive Pericarditis

• Kussmaul sign can help diagnose

Acute Cardiac Tamponade

• Management involves immediate volume expansion and pressors to maintain blood pressure
• Removal of pericardial fluid can help resolve
• Perform therapeutic pericardiocentesis
• Often performed if there are significant symptoms, when there is evidence of hemodynamic compromise
• Can be performed surgically or at bedside with echocardiographic or EKG guidance
• Place a catheter in the pericardial space to drain fluid
• Installation of medication may be required

Pericardial Effusion

• Pericardial effusion causing acute cardiac tamponade in patients with lymphoma:
  • CXR shows enlarged cardiac silhouette
  • Flask-shaped heart
  • Echo shows large effusion and chamber collapse
  • Cytological studies rule out malignancy
  • Electrical alternans

Aortic Dissection

• Patients report a sudden "ripping" or "tearing" chest or back pain
• Can be associated with pulse asymmetry, diastolic murmur (aortic regurgitation), or neurologic symptoms
• Chest X-ray may show widened mediastinum

Aortic Dissection: Marfan's Syndrome

• Initially managed with IV beta-blockers in patients with Marfan's syndrome

Abdominal Aortic Aneurysm (AAA)

• Surgical intervention is recommended in instances of AAA greater than 5.5 cm
• Surgery is recommended in instances of AAA greater than 4-5 cm in Marfan's
• Surgery is recommended for rapidly enlarging AAA
• Blood pressure control with beta-blockers is essential to slow growth
• Endovascular repair is an option

Signs of AAA

• Patients may report abdominal/back pain or a pulsatile abdominal mass
• Periumbilical pulsatile mass may be palpable during examination
• Frequently asymptomatic and discovered incidentally

Chronic Arterial Insufficiency

• Patients experience claudication (leg pain during walking, relieved by rest), cool limbs, and reduced distal pulses
• Examination reveals dependent rubor, atrophic skin, and potential ulcers.
• An Ankle-Brachial Index (ABI) less than 0.9 confirms the diagnosis, with less than 0.5 indicating severe ischemia

Arterial Obstruction of Lower Extremity

• Ankle-Brachial Index (ABI) is the best test

Buerger's Disease

• Diagnosed in young male smokers
• Causes ulceration/gangrene of fingers
• Treatment is smoking cessation

Sources of Cerebral Emboli

• Atrial fibrillation (A-fib) is the most common

Aortic Dissection Complications

• Aortic valve insufficiency can result

Ascending Aortic Dissection

• Surgery is the treatment of choice

Arterial Thrombosis

• Diagnosing acute arterial thrombosis in patients with polycythemia:
  • Presentation includes sudden leg pain, coolness, cyanosis, and absent pulses
  • Doppler or angiography confirms the diagnosis
  • Treatment involves heparin anticoagulation and urgent surgical embolectomy