Pericarditis & Myocarditis

Pericarditis and Myocarditis

Dr. Nasr Eldin Yousif Ahmed

Function of Pericardium

1. Keep the heart in its place
2. Keep the heart from expanding too much and filling the heart with too much blood
3. Protect the heart from infection
4. Provide lubrication to reduce friction between the heart and surrounding tissue

PERICARDITIS

Definition

• Pericarditis refers to an inflammatory process of the visceral and parietal pericardium as a result of bacterial, and viral infection
• Pericarditis may be acute or chronic in nature and may spread to the myocardium.

TYPES OF PERICARDITIS .

• Acute Pericarditis**
• Chronic Pericarditis**
• Constrictive Pericarditis**
• Effusive-constrictive Pericarditis**

Causes of Acute Pericarditis

• Unknown
• Viral: Coxsackie B virus, echovirus, adenovirus, HIV, Epstein – Barr virus.
• Bacterial: staphylococcus, streptococcus, haemophlus.
• Heart attack : STEMI & non-STEMI
• Chest injury
• Heart surgery

Causes of Acute Pericarditis

• Kidney filature
• Autoimmune diseases: SLE, rheumatoid arthritis, scleroderma.
• Cancer
• Drugs: INH, phenytoin, procainamide and hydralazine.

CONT.

○ Chronic pericarditis

• Pericardium becomes hard due to constrictive band around the heart, this prevent blood from filling and emptying the ventricles, resulting in cardiac failure.

ETIOLOGY

❑ Infection of heart structure may be

• Bacterial (especially by tuberculosis bacillus )
• Viral(especially by Coxsackievirus must common)
• Fungal

□ Or due to complication of systemic disease.

• Rheumatoid arthritis
• Scleroderma
• Systemic lupus erythematosus
• Myocardial infarction and
• Trauma(puncture resulting inflammation and infection)

CONT.

□ Side effect of some medication:

• Isoniazid
• Cyclosporine
• Hydralazine .

Pathophysiology: Disorders of pericardium

Signs and Symptoms

• In acute Pericarditis:
• Severe chest pain (sharp stabbing pain) due to pericardial friction.
• Radiating pain over the left shoulder, neck & back
• The chest pain is aggravated by leaning down, deep breathing, coughing and swallowing and it is relieved by sitting position & leaning forwards
• Dyspnea
• Fever

Signs and Symptoms

• Weak and small volume pulse
• Distended neck vein
• Muffled heart sound
• Pericardial rub (systolic sound)

DIAGNOSIS

• Blood testing
• Biopsy
• Electrocardiogram
• Echocardiogram
• Chest x-ray
• Cardiac computerized tomography (CT) scan
• Cardiac magnetic resonance imaging (MRI)

Universal ST segment elevation with concave upwards
PR segment depression

Diagnostic criteria for pericarditis

1. Chest pain
2. Pericardiac friction rub
3. ECG changes
4. Pericardial effusion by echo

Treatment

• Non steroidal anti-inflammatory drug
• Colchicine
  • Pericarditis
  • Gouty arthritis
• Steroids
  • Recurrent pericarditis
  • autoimmune

Constrictive Pericarditis

• It is due to progressive thickening, fibrosis and calcification of pericarditis. In effect, the heart is encased in a solid shell and cannot fill properly.
• Common causes:
  1. Tuberculous
  2. Hemopericardium
  3. Viral pericarditis
  4. Rheumatoid arthritis
  5. Purulent pericarditis

Clinical Features

• Fatigue
• Rapid, low-volume pulse
• Elevated JVP
• Kussmaul sign
• Hepatomegaly
• Ascites
• Peripheral edema
• Pulsus paradoxus

Investigations

• Chest x-ray
• Echocardiography
• CT scan

B

Management

• Medical:
  1. Loop diuretics
  2. Spironolactone
• Surgical:

Surgical resection of the diseased pericardium

Cardiac Tamponade

• This term is used to describe acute heart failure due to compression of the heart as a result of a large pericardial effusion.
• Tamponade may complicate:
  1. Any form of pericarditis
  2. Malignant diseases
  3. Trauma to the pericardium
  4. Rupture free wall of ventricle following MI

Clinical Features

• Dyspnea
• Collapse
• Tachycardia
• Hypotension
• Gross elevation of the JVP
• Soft heart sounds
• Pulsus paradoxus
• Kussmaul’s sign

Investigations

• ECG
• Chest x-ray
• Echo

L

Echo in Cardiac Tamponade

RV collapse

Management

• Cardiac tamponade is a medical emergency
• Urgent percutaneous pericardiocentesis should be performed as soon as possible which usually results in a dramatic improvement

Myocarditis

• Definition
• Causes of myocarditis
• High risk of myocarditis
• Pathophysiology of myocarditis
• Clinical features of myocarditis
• Investigation
• Management
• Complication

Definition of Myocarditis

• Myocarditis is inflammation of the heart muscle, called the myocardium.
• The condition can reduce the heart ability to pump blood.
• Others name
• Myocardial inflammation
• Heart muscle inflammation
• Inflammatory cardiomyopathy

Causes of Myocarditis

• Viral
• Bacterial
• Parasites
• Fungus
• Drugs
• chemical and radiation
• others

Viral Causes

• Adenovirus
• COVID – 19
• Hepatitis B and C
• Echo virus
• Epstein – bar virus
• German measles
• HIV
• Influenza A & B virus
• Coxsackie

Causes of Myocarditis

- Bacterial causes:

1. Staphylococcus
2. Streptococcus
3. Mycoplasma Pnemoniae
4. Bacteria that cause diphtheria
5. Bacteria that cause Lyme disease

- Parasitic causes:

1. Trypanosoma cruzi
2. toxoplasma

Causes of Myocarditis

- Fungal infection

1. Candida
2. Aspergillus
3. Histoplasma

- Drugs & alcohol

1. Anti cancer
2. Antibiotics, penicillin & sulfonamides
3. Cocaine
4. Lithium

Causes of Myocarditis

Autoimmune diseases

1. SLE
2. Rheumatoid arthritis
3. Wegener granulomatosis
4. Giant cell arteritis
5. Sarcoidosis
6. Systemic sclerosis

Chemical & radiation

1. Carbon monoxide
2. Radiation treatment of certain cancer

High Risk of Myocarditis

• DM
• HIV/AIDS
• ESRD
• Cancer treated with certain medicine
• Skin infection
• Chest injury

PATHOPHYSIOLOGY OF MYOCARDITISTHE DOMINO EFFECT

Clinical Features of Myocarditis

• Fulminant myocarditis, follow a viral prodrome and result in severe heart failure or cardiogenic shock.
• Acute myocarditis present over a long period with HF and can lead to DCM
• Chronic active myocarditis
• Chronic persistent myocarditis

Investigations

• ECG non specific changes
• Chest X-ray normal or cardiomegaly
• Echo reveal LV dysfunction
• Cardiac troponin used to monitor severity and progression of cardiac injury and myocarditis
• Endomyocardial biopsy to confirm the diagnosis

Management

• Supportive treatment
  1. Treatment of cardiac failure
  2. Treatment of arrhythmias
  3. Avoid intense physical exertion
• Specific antimicrobial therapy

THERE IS NO EVIDANCE OF BENEFIT FROM TREATMENT WITH GLUCOCORTICOIDS AND IMMUNOSUPPRESSIVE AGENT.