not all chest pain is mi: pericarditis and myocarditis
TRANSCRIPT
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Not all chest pain is MI:
Pericarditis and Myocarditis
Mary A. Stahl, RN, MSN
CNS-BC, CCNS-CMC, CCRN
Clinical Practice Specialist
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Meet KG
42 year old man
Presents with complaint of chest pain
Pain has increased over last 2 hours
Now rates it as 7/10
BP 92/50
Sinus Tachycardia, rate 116
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What might this be?
What additional information will
help make the diagnosis?
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Pericardium
Flexible double-walled membrane
Parietal pericardium
Visceral pericardium (epicardium)
Potential space between contains
15-35 mL pericardial fluid
Ultrafiltrate of blood plasma &
cardiac lymph
Lubricant to reduce interlayer friction
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Pericarditis –
Pain is most common symptom
Sharp, stabbing, pleuritic, or aching like MI
Worse with lying down, improves with
sitting up and leaning forward
Usually retrosternal, may radiate to
shoulder, neck, jaw
May complain of trapezius ridge pain,
usually on left (mediated by phrenic nerve)
Other symptoms may help indicate etiology
(fever, myalgias)
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Pericarditis – Physical exam
Friction rub
Hemodynamic change
if large effusion
Tachycardia
Tachypnea
Pulsus paradoxus
Beck triad indicates
tamponade
JVD, hypotension,
muffled heart sounds
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Pericarditis - Etiologies
Idiopathic
Infectious Viral (21%)
Bacterial
TB
Radiation
Neoplastic (35%)
Trauma
Metabolic
Cardiac Dressler’s
Aortic dissection
Autoimmune (23%) Lupus
Vasculitis
Rheumatoid arthritis
Sarcoidosis
Drug induced lupus
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Pericarditis - Evaluation
History – seek cause
EKG
Echo difficult to differentiate small effusion and pericardial thickening
R/O large effusion/tamponade
CXR boot shaped silhouette if large effusion
Labs CBC, BMP, sed rate, cardiac enzymes
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Other Imaging – Cardiac MRI
Normal Pericardial
effusion
Constrictive
Pericarditis
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Pericarditis – EKG changes
Diffusely elevated J-ST segments
ST concave (saddle-shaped) & < 5mm
Best seen in I, II, V5, V6
ST in STEMI is convex (dome-shaped) & > 5mm
elevation, localized in area
PR deviated (opposite of P-polarity)
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Pericarditis - EKG
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Electrical Alternans
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Pericarditis - Treatment
Resolve underlying cause
Rx to decrease inflammation
NSAIDs (ibuprofen 300-800 mg Q 6-8 hr
ASA
Colchicine 1-2 mg X1, then 0.5-1 mg QD
Steroids if other treatments ineffective
risk of recurrent pericarditis after taper
Limit activity
At least 3 months for athletes
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Pericardial Effusion - Treatment
Observe with serial Echo if small
Pericardiocentesis
Pericardial window if recurrent
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Constrictive Pericarditis
May be caused by: acute pericarditis
Radiation
cardiac surgery or trauma
TB
Presentation Dyspnea
Edema, ascites
Elevated JVP
Pleural effusion
Calcification seen on Echo, X-ray, CT or MRI in 30%
Echo R & L pressures
Tricuspid regurg
Abnormal septal motion
Impaired filling
Treatment Medication
Pericardectomy
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Myocarditis
Symptoms
Chest pain – 35%
CHF
Malaise
Syncope
Palpitations
Fever – 20%
Fulminant myocarditis
Sudden onset of HF within 2-3 weeks of
viral illness
presents with hemodynamic
deterioration, cardiogenic shock
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Myocarditis - Etiologies
Viral Coxsackie
Herpes
Parvo
CMV
Epstein-Barr
Hepatitis C
Other adenoviruses
Other endoviruses
Lyme disease
Bacterial
Strep, staph
diptheria
Protozoic (ie Chagas)
Paracytic
Toxins
Hypersensitivities, as
with antibiotics
Drugs from cocaine to
acetaminophen
Chemo- & cytokines
Immunologic (SLE)
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Myocarditis
Pathophysiology
Uptake of viral RNA causes cytotoxic necrosis
Interstitial infiltrate
Infiltration of mononuclear cells
Killer cells target the myocardial cells expressing viral RNA and continue necrosis
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Myocarditis – Physical Findings
Wide varibility
Tachycardia out of proportion to fever
Signs of CHF
Mitral and tricuspid regurg from
ventricular dilatation
If inflammation diffuse, may also have
pericarditis symptoms and rub
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Myocarditis – EKG changes ST elevation – diffuse, no reciprocal changes
Q waves
AV and intraventricular conduction delays
Tachydysrhythmias
Low voltage
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Myocarditis - Diagnosis
ESR elevated – 60%
Cardiac enzymes often negative
If elevated – slower rise and fall
Leukocytosis – 25%
CXR may be normal, or show CHF
Due to presentation and EKG
changes, often these patients are
taken to cardiac cath, and found to
have insignificant or no CAD
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Myocarditis - Diagnosis
Echo –
chamber dilatation or segmental wall motion abnormality along with a small pericardial effusion
Decreased EF
MRI – tissue edema, capillary leakage
Biopsy –
Inflammation with >14 lymphocytes & macrophages/mm2
Allows identification of infective agent
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Myocarditis - Treatment Supportive
CHF management
Rhythm management
Limit activity for 6 months
Viral – immunoglobulin, anti-viral
Giant cell – immunosupression
Fulminant myocarditis
IABP as needed if cardiogenic shock
Ventricular assist device
Severe acute myocarditis
Ventricular assist device
unloads ventricle, bridge to recovery
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Myocarditis - Outcomes
The amount of myocardial damage is
variable
insignificant
extensive damage leading to dilated
cardiomyopathy
Some “idiopathic” cardiomyopathies
are suspected to be due to recurrent,
subclinical myocarditis
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Remember KG?
42 year old man
Presents with complaint of chest pain
Pain has increased over last 2 hours
Heavy, aching
Now rates it as 7/10
BP 92/50
Sinus Tachycardia, rate 116
Temperature 101.4
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KG
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KG
Recent upper respiratory infection
Troponin 0.79
CK-MB 8.2
WBC , ESR
Echo
segmental wall defects
EF 37%
LV dilitation
CXR – pulmonary congestion, effusion
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Case Study #2 - CE
CE is a 54 year old woman
Presents with complaint of chest pain
Pain has been present for 3 hours
No relief with antacids,
acetaminophen
Rates pain as 6/10
BP 147/86
Sinus rhythm, rate 96
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CE
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CE – What do you want to know?
History Physical exam
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CE – What tests? Diagnosis?
Tests Diagnosis
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CE – Treatment?