Acute Pericarditis/

ECG conference
Jimmy Klemis, MD
Jan 8, 2002
Pericardium
Visceral / serous
Direct contact with epicardium (ST elev)
single layer mesothelial cells
Parietal / fibrous
mesothelial and fibrous layer

Pericardial Anatomy
Visceral transparent

Parietal translucent

Transverse sinus curved probe
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
Acute Pericarditis Clinical
History
preceding viral illness, etc
Symptoms
Chest pain
Signs
Friction Rub
ECG
early: PR / ST changes
late: isoelectric ST/ T inv
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
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)
ECG
PR depression
ST elevation
concave up, ST/T V6 >.25, no reciprocal
DDx:
Acute MI
Early Repolarization
Myocarditis
Aneurysm
other: Brugada, BBB
ECG
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 I
1

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 6
th


Acute PCARD Stage I, II
60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs,
* Marriotts Practical ECG 10
th
ed, p 208
Acute PCARD Stage III
19 y/o Female after 1 wk in hospital with Acute Pericarditis
DDx: PCARD vs Repol
Acute
Pericarditis
Early
Repolarization
Sex Either Usually Male
Age Any Usually < 40
PR segment dev Common Uncommon
T waves nl, blunt tall, peaked
J-ST / T ampl V6 > 25% <25%
Tallest
precordial R
Usually V5 Usually V4
DDx: PCARD vs MI
Pericarditis Angina, ischemia
J-ST
Diffuse concave
elevation w/o reciprocal
changes
Localized, convex, w/
reciprocal changes in
infarct
PR depression
Frequent Almost never
Q waves
Not usual, unless with
infarct
Common with q wave
infarct
T waves
Inverted after J returns
to baseline
Inverted while ST still
elevated
Arrhythmia
Rare Frequent
Conduction
disturbances
Rare frequent
Cardiac Isoenzymes - ? helpful
2 year study, ER based
1

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

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 (p<.00001)
in largest multicenter trial to date
1
Anecdotal evidence of benefit in Acute PCARD, effusion
1
Adler Y, et al. Circulation, 1998 June 2

Complications
Pericardial Effusion/Tamponade
Constrictive Pericarditis
can be transient 10% may have transient
sxs within 1
st
month, resolves by 3 months
Recurrent Pericarditis (20-25%)
Rx NSAIDS/Colchicine +/- steroids
Gross Pathology
Bread & Butter appearance Fibrinous stranding
Acute PCARD Stage I
ECG Quiz
Acute Pericarditis, Stage I
ECG quiz 2
Acute Ant MI
ECG quiz 3
Early Repolarization
ECG quiz 4
Early Repolarization
ECG Quiz 5
Pericardial dz, diffuse ST elev
ECG Quiz 6
ECG Quiz 6a
Acute antseptal MI
ECG Quiz 7
Early Repolarization
ECG quiz 8
Incomplete RBBB