Pericarditis, Endocarditis,

Myocarditis
Victor Politi, M.D., FACP
Medical Director, SVCMC,
School of Allied Health
Professions, Physician
Assistant Program

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, Bhemolytic 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 antiDNA 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 PericarditisTreatment
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, Bhemolytic 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 unsuccessfulconstrictive 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, gramnegative 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 highpressure 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 ?