Cardiology

What is acute pericarditis?

It is inflammation of the sac that surrounds the heart which is called the pericardium.

What is the pericardium?

It is a fibroelastic sac which surrounds the heart and isolates it from the surrounding organs. The lungs have their own sac as well.

What types of pericarditis are there other than acute?

We’ll discuss them later but we have acute pericarditis, recurrent pericarditis, incessant pericarditis, and chronic pericarditis

Why does the pericardium get inflamed?

The inflammation can be caused by any injury to the pericardium. Infections can cause it, mostly viral, but bacterial and fungal infections can cause it as well. Virtually any infection can cause pericarditis. The most common viral causes are coxsackievirus and echo virus. Other causes include radiation to the chest, post-myocardial infarction, uremia, malignancy, immune mediated, drugs, and others.

What kind of drugs?

No need to memorize this but some notorious ones are Procainamide, hydralazine, isoniazid, methyldopa, phenytoin, penicillin, minoxidil, Doxorubicin, daunorubicin. Most common etiology is really viral infection.

Penicillin?

Yes, it may cause a hypersensitivity pericarditis with eosinophilia

How does an acute pericarditis patient present?

Patients usually have a typical chest pain and EKG changes (diffuse ST elevation or PR depression). Other clues that can make us think of pericarditis, which may or may not be present, are a friction rub on cardiac exam, pericardial effusion on echo, fever.

What is the typical chest pain?

It is a pleuritic chest pain. Sharp and midsternal. Worsens with deep inspiration and lying back and improve with sitting up or leaning forward.

What do we do if we suspect it?

Pericarditis is a clinical diagnosis. When a patient has chest pain and these EKG changes we have a high suspicion for it, especially if there is another factor such as infection or malignancy in the picture. We send CRP and ESR which helps us confirm that there is an inflammatory state and which serves as a marker that we can follow. Other tests that we could do depend on what we think the likely etiology is.

Are there diagnostic criteria to follow?

It is usually based on the general clinical judgement but if helpful, the following criteria can be used: two or more of the following: typical chest pain; typical EKG changes; friction rub on exam; new or worsening pericardial effusion.

What is the treatment?

We usually start patients on high dose NSAID (eg: ibuprofen 600-800 mg TID for one week, tapered by 200 mg per week once the patient is asymptomatic for at least 24 hours and the CRP has normalized) and Colchicine 0.6 mg BID for 3 months (or 0.6 mg daily if the patient’s weight is <70kg).

Any variations to this treatment?

Another NSAID that can be used is Indomethacin 25-50 mg TID for one week and tapered by 25 mg per week when symptoms resolve for 24 hours and CRP normalizes. If the patient had an MI then we would replace NSAID with high dose aspirin (650-1000 mg TID for 1-2 weeks, tapered by 250 mg weekly when asymptomatic for 24 hours and CRP normalizes.)

Do patients need PPI with this much NSAID?

Certain patients, those who have a history of peptic ulcer disease, age > 65 years, and concurrent use of aspirin, steroids, or anticoagulation.

Any other treatments?

Prednisone can be used as a second line therapy in place of the NSAID or ASA but it is not preferred since there is a high chance of recurrent pericarditis with the use of steroids.

Why would we use steroids then if it causes recurrent pericarditis?

It would only be used if we can’t use NSAIDs due to MI or renal disease or pregnancy > 20 weeks for example and we can’t use aspirin for some reason such as bleeding risk. It can sometimes be added to ASA in refractory cases where the patient has been on ASA and colchicine.

Any other therapies?

There are treatments that are used if nothing else works. Pericardiectomy (removal of the pericardium), Rilonacept, Anakinra, Azathioprine, IVIG.

Does a patient need to be admitted if they are diagnosed with pericarditis?

High risk patients do. Some low risk patients can be evaluated and sent home with a prescription.

Who are the high-risk patients?

Anyone who has a fever, has a subacute course (no acute chest pain), hemodynamically unstable (naturally, but it also suggests possible tamponade), large pericardial effusion, immunosuppressed patients, patient taking anticoagulation, trauma, elevated troponin (suggesting myopericarditis).

Anything else?

Yes, activity restriction. It is based on experts’ opinion and there are no data for it but we recommend avoiding all strenuous activity until symptoms resolve and markers normalize.

What is the prognosis like?

It depends on the etiology. Patients with acute idiopathic or viral pericarditis have a good long-term prognosis. Those who have malignancy, tuberculosis, or purulent pericarditis have a worse prognosis due to risk of cardiac tamponade. Women are at increased risk of complications.

As the world continues to grapple with the ongoing COVID-19 pandemic, more and more attention is being paid to the wide range of health issues that have arisen in its wake. One of the most concerning of these is the growing incidence of myocarditis, or inflammation of the heart muscle, among people who have had COVID-19.

Myocarditis is a serious condition that can lead to heart failure and even death if left untreated. It occurs when the immune system mistakenly attacks the heart muscle, causing inflammation and damage. This can lead to a range of symptoms, including chest pain, shortness of breath, palpitations, and fatigue.

The exact cause of COVID-induced myocarditis is still not fully understood, but it is believed to be related to the body's immune response to the virus. Some experts believe that the virus itself may directly attack the heart muscle, while others believe that the immune response to the virus may be responsible for the inflammation.

There is also evidence that people who have had COVID-19 are at a higher risk of developing myocarditis, especially if they are young and previously healthy. This is especially concerning given that many people who are infected with COVID-19 may not show any symptoms at all, making it difficult to identify and treat myocarditis in its early stages.

If you have had COVID-19 and are experiencing symptoms of myocarditis, it is important to seek medical attention as soon as possible. Your doctor will likely perform a physical examination, and may order tests such as an ECG or echocardiogram to check for any signs of inflammation or damage to the heart muscle.

Treatment for myocarditis typically involves medications to reduce inflammation and prevent further damage to the heart muscle. In some cases, hospitalization may be necessary to monitor the patient's condition and provide supportive care.

It's important to remember that myocarditis is just one of the many potential complications of COVID-19, and that the best way to protect yourself and others is to take all the necessary precautions to prevent infection in the first place. This includes getting vaccinated, wearing masks, practicing social distancing, and washing your hands frequently.

In conclusion, myocarditis is a serious condition that can occur after COVID-19. It is important to understand the risks and symptoms of this condition and seek medical attention if you experience any symptoms. We must continue to be vigilant and take all necessary precautions to protect ourselves and others from this virus.