ZSFG MORNING REPORT PEARLS 10/19/16: Pericarditis and Cardiac Procedures!

Thanks to Alex, Ashley, and Arvind (AAA?) for presenting the case of a middle-aged man with recurrent pericarditis! We discussed a couple of cardiac procedures. We also discussed his macrocytic hypoproliferative anemia and thrombocytopenia with a pending bone marrow biopsy, but the pearls will focus on the cardiac elements of the case. Thanks ZSFG for having me as your guest today!

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Top Pearls:

  1. Most pericarditis cases are idiopathic!
  2. Treatment of recurrent pericarditis is similar to treatment of the initial episode, with 1st line being NSAIDs + colchicine.
  3. Diagnostic yield of pericardiocentesis is relatively low (<40%)

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For those interested in more info:

Acute and Recurrent Pericarditis

Etiology:

  • Most cases are idiopathic! (presumed viral or immune-mediated)
  • Infectious: Viral, TB, Bacterial, Fungal, Parasitic
  • Non-infectious:
    • Autoimmune (SLE, RA, Sjogren, Scleroderma, MCD, vasculitis)
    • Neoplastic (lung, breast, Hodgkin, leukemia, melanoma, paraneoplastic)
    • Metabolic (Hypothyroid, Uremia)
    • Post-Cardiac Injury
    • Trauma
    • Radiation
    • Meds

Treatment:

  • For acute pericarditis, NSAID x 1-2 weeks + colchicine x 3 months. Preferred NSAIDs are ibuprofen or indomethacin. Aspirin may also be used. All are TID!
  • Treatment of recurrent pericarditis is the same as acute! Except colchicine duration is extended to at least 6 months.
  • For post-MI pericarditis, aspirin + colchicine is preferred. Recommended to avoid other NSAIDs and steroids in this setting.
  • For refractory cases, contraindication to NSAID, or autoimmune etiology, regimen is prednisone + colchicine
  • Adding colchicine reduces recurrence rate!
  • Recurrent pericarditis occurs in 1/3 of patients with acute pericarditis
  • Steroids may increase the risk of recurrence
  • Pericardiectomy if chronic symptomatic constrictive pericarditis refractory to medical therapy

Pericardiocentesis indications

  • Therapeutic for tamponade
  • Suspicion for purulent, tuberculous, or neoplastic pericarditis
  • Moderate to large pericardial effusions of unknown etiology that do not respond rapidly to anti-inflammatory therapy
  • Diagnostic yield relatively low (<40%)

Endomyocardial biopsy (EMB)

  • Main value is dx of uncommon myocardial disorders such as giant cell myocarditis, hypereosinophilia, sarcoidosis, and other cardiomyopathies/myocarditis
  • Also useful for select cases of heart failure, dilated CM, and select cardiac tumors if other evaluation inconclusive
  • Usually RV biopsy (venous approach), more rarely LV (arterial approach) due to risk of perforation and stroke
  • Clinical diagnosis ultimately established in 50% of cases, but specific histologic diagnostic yield of EMB only 15% (mostly myocarditis and infiltrative disease)

Evernote: https://www.evernote.com/shard/s272/sh/79567f20-47c7-4641-92ea-03704a13c9f8/5a69f3a28cc806132efac8013abb93a6

Have a great day everyone!

Sam

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