Non infectious causes os pericarditis
neoplastic
metabolic
traumatic
post-acute-MI (Dressler Synd)
iatrogenic (Covid vaccines)
Cardiac tamponade triad (Beck’s)
soft heart sounds
elevated jugular venous pressure
hypotension
How to investigate a patient with pericarditis suspicion
ECG
chest X-ray
markers of inflammation (eg CRP, ESR, WCC)
cardiac troponin concentration (marker of myocardial injury)
transthoracic echocardiogram.
Diagnostic criteria for pericarditis
At least 2:
pericarditic chest pain
pericardial rubs
new widespread ST elevation or PR depression on electrocardiogram (ECG)
pericardial effusion (new or worsening)
Acute pericarditis treatment
Colchicine + NSAID (+ cortics if NSAID CI)
Colchicine:
70 kg or more: 500 micrograms orally, twice daily for 3 months
less than 70 kg: 500 micrograms orally, once daily for 3 months
+
aspirin 750 to 1000 mg orally, 8-hourly for 1 to 2 weeks, then decrease the dose by 250 to 500 mg every 1 or 2 weeks to stop
OR
ibuprofen immediate-release 600 mg orally, 8-hourly for 1 to 2 weeks, then decrease the dose by 200 to 400 mg every 1 or 2 weeks to stop
Endocarditis Diagnosis
Duke’s criteria: (2 major and 1 minor criterion OR 1 major and 3 minor OR 5 minor)
MAJOR:
- Positive blood cultures for infective endocarditis typical microorganism from 2 separate blood cultures 12h apart (Viridans streptococci, Streptococcus bovis, HACEK group OR community-acquired S. aureus or enterococci in the absence of a primary focus)
- Evidence of endocardial involvement
(positive echocardiogram for infective endocarditis or regurgitation)
- Single positive blood culture for Coxiella Burnetii or antiphase I IgG antibody titer >1:800
MINOR:
- predisposing heart condition or intravenous drug use
- fever: 38°C
- vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
- immunologic phenomena: glomerulonephritis, Osler nodes; Roth spots; rheumatoid factor
- microbiologic evidence: positive blood culture but not meeting major criteria or serologic evidence of active infection with organism consistent with infective endocarditis
- echocardiography findings consistent with infective endocarditis but not meeting major criteria
Native valve Endocarditis’ treatment
- Empirical (4-6 weeks):
Benzylpenicillin 1.8 g intravenously, 4-hourly
+
Flucloxacillin 2 g intravenously, 4-hourly
+
gentamicin intravenously over 3 to 5 minutes:
– with septic shock and without kidney impairment: 7 mg/kg, for the first dose
– without septic shock: 4 to 5 mg/kg for first dose
! If MRSA suspected or shock at initial presentation:
– replace benzylpenicillin with vancomycin (adult and child) 25 to 30 mg/kg intravenously
! If hypersensitivity to penicillins:
Cefazoline 2g 8-hourly
+ vancomycin + gentamicin
Therapy for prosthetic valve and cardiac implantable electronic device-associated infective endocarditis
Flucloxacilin + vancomycin + gentamicin
When is prophylaxis for endocarditis indicated?
For patients who meet both of the following criteria:
- Have a cardiac condition associated with an increased risk of developing infective endocarditis and the highest risk of adverse outcomes from endocarditis:
– rheumatic heart disease; prosthetic cardiac valve, including transcatheter-implanted prosthesis; previous infective endocarditis;
congenital heart disease but only if it involves: unrepaired cyanotic defects, including palliative shunts and conduits
repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)
!! Not patients with cardiac implantable electronic devices. - Are undergoing a procedure associated with a high risk of a bacteraemia that is associated with endocarditis
– Dental procedures; dermatological or musculoskeletal procedures — only those involving infected skin, skin structures or musculoskeletal tissues.
Respiratory tract or ear, nose and throat procedures; Genitourinary and gastrointestinal tract procedures—only if surgical antibiotic prophylaxis is required or for patients with an established infection
Prophylatic treatment for infective endocarditis:
amoxicillin 2 g (child: 50 mg/kg up to 2 g) orally, 60 minutes before the procedure.
What’s the more usual sign find on EKG in WPW disease?
Delta wave
What’s the finding on EKG in pericarditis?
Wide spread concave ST elevations
What are the drug most commonly associated with EKG findings?
Digoxin and anti-convulsivants/antipsychotics
What’s the finding on EKG in digoxin toxicity?
infra-desnivelamento “curvo” do segmento ST
Whats’ the EKG finding in hipocalcemia?
ST segment and QT interval shortening
What’s the EKG findings in hipokalemia?
- U wave
- Long PR interval
- Depressed ST segment
- Inverted and shallow T waves
Most common cause of pericarditis
Viral
Coxsackie B, influenza and Epstein-Barr viruses.
What’s the first line treatmente for HAS in patients 65>?
Low-dose thiazide diuretic
!!!They are not recommended for younger patients due to the risk of diabetes associated with long-term use.
What’s the long term use risk associated with thiazide diuretics?
DM
What’s the findings in the physical exam of aortic valve stenosis?
Ejection systolic murmur heard best at the upper right sternal border and a slow-rising pulse. Decreases with valsalva manoeuvre.
What’s the findings in the physical exam of Hypertrophic obstructive cardiomyopathy (HOCM)
Ejection systolic murmur that increases with valsalva manoeuvre
What’s Dressler’s syndrome?
An autoimmune pericarditis that occurs up to six weeks post-AMI.
What’s Kussmaul’s sign?
An increase in the jugular venous pulse during an inspiration. A sign of right ventricular insuficiency. Also common in pericarditis.
Electrical alternans in ECG indicates…?
Pleural effusion or Cardiac Tamponade
Alternating QRS amplitudes in any or all leads on an electrocardiogram (ECG) with no additional evident changes in conduction pathways of the heart.
