​Kembara Xtra - Medicine - Pericarditis

​Kembara Xtra - Medicine - Pericarditis 
Pericardial inflammation, either with or without pericardial effusion. Myopericarditis, also known as perimyocarditis, describes conditions when the myocardium is also affected.

Epidemiology Incidence There aren't enough epidemiological research.  After first episode of acute pericarditis, about 30% of patients will experience recurrence within next 18 months. Exact incidence is unknown, but occurs in up to 5% of patients evaluated in the emergency room (ER) for chest pain without myocardial infarction (MI), including children; there appears to be a slightly increased prevalence in men ages 16 to 65.

Pathophysiology and Etiology 
Pericardial sac inflammation can be acute, chronic (disease process lasting more than 3 months), or recurrent (subsequent event occurring 4-6 weeks after the initial episode without symptoms).
Constrictive pericarditis can be brought on by ongoing or persistent inflammation.
 Depending on the etiology, it may or may not create serous/purulent fluid/dense fibrinous material, which could affect hemodynamics.
 85–90% of instances are idiopathic; they are probably caused by viral infections, which might set off immune-related processes.
Coxsackievirus, echovirus, adenovirus, Epstein-Barr virus, cytomegalovirus, hepatitis viruses, influenza virus, HIV, measles, mumps, and varicella are examples of infectious - viral diseases.
Mycobacterium tuberculosis is the most frequent type of bacteria, while other bacterial causes are uncommon.
- Fungi: Histoplasma capsulatum, Candida sp., and Blastomyces dermatitidis (particularly prevalent in immunocompromised populations).
- Echinococcus parasites Noninfectious causes
- Dressler syndrome (weeks to months after MI), acute MI (two to four days after MI).
- Renal failure, uremia, and dialysis-related conditions
- Malignancy (such as lymphoma, leukemia, Hodgkin disease, breast cancer, and lung cancer)
Radiation treatment
Trauma following cardiac procedures (such as catheterization, pacemaker implantation, ablation, and pericardiotomy), for example
Connective tissue disorders, rheumatoid arthritis, scleroderma, hypothyroidism, inflammatory bowel disease, Wegener granulomatosis, spondyloarthropathies, and sarcoidosis are examples of autoimmune disorders.
Dantrolene, doxorubicin, hydralazine, isoniazid, mesalamine, methysergide, penicillin, phenytoin, procainamide, and rifampin are examples of medication-induced illnesses.
Genetics
unknown causes

Risk Elements 
Having thoracic surgery, having chronic renal illness, pneumonia, autoimmune diseases, having radiation therapy for breast or lung cancer, or having any of these conditions

Basic Prevention 

Use of masks and good hygiene, including hand washing


Conditionalities Dependent on Etiology

Diagnosed with acute pericarditis (at least two of four diagnostic clinical criteria)
 Typical chest pain (pleuritic)
(33% of instances) Pericardial friction rub
 Widespread (non-regional) ST-segment elevations on the ECG (up to 60% of cases)
 Imaging revealed a new or growing pericardial effusion due to myopericarditis.
1. Clearly evident pericarditis and
2. On an imaging study, symptoms (such as dyspnea, chest discomfort, or palpitations) and ECG changes (such as aberrant ST/T waves or ventricular or supraventricular tachycardia) that had not previously been reported are present. 3. There is no other obvious reason.
4. Creatine kinase [CK]-MB, troponin I or T elevations, new focal or diffuse LV dysfunction, aberrant imaging consistent with myocarditis (MRI with gadolinium, gallium-67 scanning, antimyosin antibody scanning), or any one of the following.
- Myopericarditis case definitions based on the aforementioned standards:
Myopericarditis suspicion: 1, 2, and 3; myopericarditis likelihood: 1, 2, 3, and 4
Confirmed myopericarditis: endomyocardial biopsy (EMB) or autopsy histopathologic evidence of myocarditis (Note: EMB is infrequently recommended in the clinical environment for self-limited cases with a predominance of pericarditis.)

Presenting History: Prodrome of fever, malaise, myalgias, and viral upper respiratory; acute, stabbing chest pain; pathognomonic if pain radiates to the trapezius; duration usually lasting hours to days; pleuritic pain; discomfort made worse by resting supine; shortness of breath.

clinical assessment 
Pericardial friction rub: coarse, high-pitched sound best heard at end expiration near left lower sternal border with patient bending forward. Heart rate is often regular but may be fast. New S3 may indicate myopericarditis or cardiac tamponade; very specific for diagnosis (but not sensitive); transient and mono-, bi-, or triphasic

Initial test results from the laboratory and imaging
For straightforward instances or where the diagnosis is obvious, particularly in nations with low tuberculosis prevalence, it is not required to order tests. The tests listed below may be useful:
- A typical leukocytosis finding on the CBC
- Elevated levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and lactate dehydrogenase (LDH) are indicative of inflammation.
Cardiac biomarkers include troponins and frequently high CK.
 Adverse outcomes are not predicted by increased troponin. increased troponins related with younger age, male sex, pericardial effusion at presentation, and ST segment elevation on ECG.
In all or most leads, there is widespread upward concave ST segment elevation, which is a diffuse, nonregional process. There is also PR segment depression, which may go through four stages. ECG may be normal or exhibit vague abnormalities:
Widespread ST segment elevation and PR segment depression in Stage 1.
- Stage 2: The ST and PR segments normalize, and the T waves start to flatten and invert.
extensive T wave inversions, stage three.
- Stage 4: T waves return to normal; if there is chronic pericarditis, there may still be residual inversions.
The ECG may show electrical alternans, low voltage, massive effusions, and tamponade.
To check for pericardial effusion, tamponade, or myocardial illness (the presence of effusion aids in the confirmation of the diagnosis of pericarditis), a transthoracic echocardiography is advised. On echo, effusions are easily diagnosed.
A chest x-ray (CXR) is used to rule out mediastinal or pulmonary abnormalities. Large pericardial effusion (at least 300 mL) is suggested by an enlarged cardiac silhouette.
The pericardium can be seen using CT and MRI to check for problems or if the initial workup is ambiguous.
Additional tests may include HIV serology, sputum cultures, rheumatoid factor, antinuclear antibody, and tuberculin skin test (if clinically relevant based on history or an unusual presentation or course).
Antibody titers and viral cultures are rarely clinically helpful.
Other/Diagnostic Procedures
 Pericardiocentesis should be performed if there is cardiac tamponade, if purulent, tuberculous, or neoplastic pericarditis is suspected, or if there are effusions larger than 20 mm on echocardiography. If there is persistent tamponade, inadequate pericardiocentesis, or hemodynamic instability, surgical drainage with pericardial biopsy is advised.

Microscopic inspection may show hyperemia, leukocyte encrustation, or fibrin deposition.
 If bacterial etiology, purulent fluid with a neutrophil predominance will be present.
Viral, tuberculous, and neoplastic pericarditis all have a predominance of lymphocytic cells.


Treatment's objectives include minimizing consequences (such as recurrence, tamponade, and chronic constrictive pericarditis) and relieving discomfort.
85% of patients with low-risk traits who receive outpatient therapy are said to be effective.

General measures For individuals with a cause other than a viral or idiopathic condition, specific medication targeted at the underlying disorder should be used. Physical activity limitations are a crucial component of the treatment for recurrences.

First Line of Medicine
NSAIDs are regarded as the cornerstone of treatment for acute pericarditis:
- 600 mg of ibuprofen TID for 1–2 weeks (2–4 weeks for recurrence), then taper- Patients with recent MI should take aspirin 750–1000 mg TID for 1–2 weeks (2–4 weeks for recurrence), then taper down because other NSAIDs have been shown to hinder scar development in animal studies.- Indomethacin 50 mg TID for 1–2 weeks (2–4 weeks for recurrence), then taper; older patients should avoid due to coronary artery flow restriction- Ketorolac 15 to 30 mg IV/IM every six hours while a patient; for a maximum of five days. - GI protection ought to be offered.
- Only if the patient is asymptomatic and the CRP/ESR are normal should tapering be performed. Every 1 to 2 weeks, repeat the CRP/ESR.
- Initial episodes can be treated with NSAIDs for 1 to 2 weeks, but recurrences may require 2 to 4 weeks of medication.
- Monitoring: NSAIDs: CBC and CRP at baseline and every week until CRP returns to normal - Contraindications: Hypersensitivity to aspirin or NSAIDs, active peptic ulcer, or GI bleeding - Precautions: In individuals with coagulopathy, renal/hepatic failure, asthma, or pregnancy in the third trimester, use with caution.
Colchicine is frequently used in conjunction with NSAIDs to reduce the likelihood of recurrence and speed up symptom relief; the dosage is 0.6 mg BID for up to 3 months (up to 6 months for recurrence); tapering is not necessary. This is the only medication that has been shown to do so in RCTs.
By 50%, adjunctive therapy can lower the rate of recurrence. Consider CBC, CRP, transaminases, CK, and creatinine at baseline and at least one month beyond that while monitoring.
Pregnant women should avoid NSAIDs, aspirin, and colchicine while using prednisone. Aspirin is recommended for use in the first 20 weeks of pregnancy, but NSAIDs and other pain relievers are also OK.

Next Line
Corticosteroid therapy is advised against in cases of uncomplicated acute pericarditis or if an infectious etiology is suspected. It is appropriate in cases of connective tissue disease, tuberculous pericarditis, or severe recurrent symptoms that are not relieved by NSAIDs or colchicine. It has been discovered that corticosteroid use alone is a separate risk factor for recurrence.
● If steroids are used, consider low dose (0.20 to 0.50 mg/kg/day until resolution of symptoms and normalization of CRP, then consider slow tapering (if >50 mg: 10 mg/day every 1 to 2 weeks; if 25 to 50 mg: 5 to 10 mg/day every 1 to 2 weeks; if 15 to 25 mg: 2.5 mg/day every 2 to 4 weeks; if <15 mg/day: 1.0 to 2.5 mg/day every 2 to 6 weeks). Reduce taper to 1.0-2.5 mg every 2–6 weeks at the threshold of 10-15 mg/day to avoid recurrence.
● Keep in mind the need for sufficient prophylaxis in the fight against osteoporosis.
 If a recurrence occurs while tapering, try not to up the dose or start the corticosteroid cycle.
Steroids used intrapericardially may be effective and limit systemic side effects. Azethioprine, IV human immunoglobulins, and anakinra are developing alternatives.

Problems to Refer 
Any patient with significant medical comorbidities, suspected or imminent tamponade, poor prognostic characteristics (see next column), or a presentation that raises suspicion of a systemic inflammatory disease are suggested for hospitalization for etiology evaluation.
Refractory instances consist of those who are taking excessively high long-term steroid doses (more than 25 mg/day).
Consider experimenting with aspirin, NSAIDs, steroids, and colchicine.
 Dialysis-related or uremic situations necessitate more frequent or urgent dialysis without significantly enhancing the efficacy of pharmaceuticals.

Surgical Techniques 

Pericardiocentesis is recommended in situations when there is cardiac tamponade, a high risk of developing tuberculous, purulent, or neoplastic pericarditis, and moderate-to-large symptomatic effusions that are resistant to conventional medical treatment.
Pericardioscopy for targeted diagnostic imaging may be carried out at skilled tertiary referral centers in refractory and challenging cases. Pericardial biopsy may be considered for diagnosis in people with persistent worsening pericarditis without a conclusive diagnosis.
Pericardiectomy is the standard of care for chronic constrictive pericarditis with persistent symptoms, such as NYHA class III or IV. Pericardial window may be performed in cases of recurrent cardiac tamponade with significant pericardial effusion despite medicinal therapy and severe symptoms. Mortality is significant (6-12%), hence pericardial disorders are only reserved after careful review by skilled surgeons at facilities with a focus on pericardial diseases.


Admission 

 Pericarditis related with clinical predictors of poor prognosis and indicated for inpatient therapy:
- Important risk factors include a fever of at least 38 degrees Celsius, subacute onset, a significant pericardial effusion, cardiac tamponade, and a lack of response to NSAID/aspirin therapy after at least a week.
Consider IV fluids for hypotension or in the presence of pericardial tamponade. Minor predictors: immunosuppressed status, trauma, oral anticoagulant medication, and myopericarditis. Discharge criteria: Response to therapy with symptom improvement; hemodynamic stability.


Follow-up Based on lab results and echocardiographic findings, those with clinical predictors of poor prognosis may need closer follow-up. Follow-up 7 to 10 days to assess response to treatment; 1 month to examine CBC and CRP; and thereafter, if symptoms persist.
Monitoring the patient's myopericarditis
Utilize lower anti-inflammatory medicine dosages to manage symptoms for one to two weeks while limiting negative effects on the myocarditic process.
 Limiting physical activity for 4 to 6 weeks, or until symptoms disappeared and biomarkers returned to baseline. Exercise limitation for athletes should start at least three months following the onset of symptoms.
 Follow-up with an echocardiogram at 1, 6, and 12 months, especially in patients with LV dysfunction


diet tailored only to the underlying cause

Overall favorable prognosis; the illness is typically benign and self-limiting; purulent and tuberculous pericarditis have a high fatality rate.

Complications 
Recurrent pericarditis affects about 30% of patients and is typically brought on by idiopathic, viral, or autoimmune pericarditis, insufficient initial treatment, and, less frequently, neoplastic etiologies.
Recurrence typically occurs during the first week after the original episode, but it can also happen months or years later. It is rarely accompanied by tamponade or constriction.
 Colchicine resistance and corticosteroid dependency occur in about 5% of patients.
Cardiac tamponade is an uncommon consequence that is more common in pericarditis that is neoplastic, purulent, or tuberculous.
 Effusive-constrictive pericarditis: reported in 24% of patients having constrictive pericarditis surgery and in 8% of patients having pericardiocentesis and cardiac catheterization for cardiac tamponade. After pericardiocentesis, the right atrial pressure must drop by 50% or to a level below 10 mm Hg in order to be diagnosed.
Constrictive pericarditis is a very uncommon condition that causes incorrect diastolic filling and high filling pressures. The only effective treatment option is pericardiectomy.
BIBLIOGRAPHY 1. Imazio M, Brucato A,

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