Carditis: Inside and Out Derek Brown, MD SAUSHEC Military EMS & Disaster Medicine Fellow Pericarditis Bruce Blaus https://commons.wikimedia.org/wiki/File:Pericarditis.png Pericarditis 0.1% of Hospitalized Patients 5% of ED Patients with non-ACS CP 80-90% Viral Complications: 21% Patients 18% recurrence 3-5% tamponade 2% constrictive pericarditis Pericarditis Not ACS Not Tamponade Not Myocarditis Pericarditis ECG James Heilman, MD https://commons.wikimedia.org/wiki/File:PericarditisMyocarditis.jpg Pericarditis STEMI Tamponade Pericarditis vs Myocarditis Pericarditis – 70% cases Myopericarditis – 25% cases Perimyocarditis – 5% cases Troponin Elevation: Ventricular Arrhythmias Heart Failure Reduced LVEF High Risk Features Fever >38°C (100.4° F) Subacute Course (several days – weeks) Cardiac Tamponade Large Pericardial Effusion (end-diastole Echo-free space >20mm) Immunosuppression / Immunocompromised Anticoagulation Use Trauma Failure of NSAID and/or Colchicine Elevated Troponin Myocarditis Variable Presentation: Viral Illness Cardiogenic Shock 41 – 89% Viral Prodrome Enterovirus, Adenovirus, Parvo B19, HHV 6 Severe Myocarditis 5yr Survival: 56% Pediatric: 90% with 80% requiring ICU care Myocarditis Presentation Pediatric Series: Key Features: 45% Chest Pain - EKG Changes of Myocardial 28% Resp. Distress Injury 27% GI Sx - Rise in Troponin 16% Poor Perfusion - Arrhythmia 41% Viral Prodrome - New/Unexplained Cardiac Dysfxn - Tachycardia Out-Of-Proportion Emergency Management Pediatric Series: 45% Significant Arrhythmia Frank Gaillard https://commons.wikimedia.org/wiki/File:AP_portable_CXR_of_a_patient_in_acu te_pulmonary_oedema.jpg Cardiogenic Shock Broad Differential Inotropes Mechanis Effect Adverse m Trial of IV Fluid Dobutamine Inodilator ↑Contract ↓SVR Hypotension Milrinone Inodilator ↑Contract ↓SVR Hypotension Inotropes Dopamine Mixed ↑Contract ↑↓SVR Arrhythmia, ↑ Mortality Norepinephrine Inopressor ↑Contract ↑SVR Positive Pressure Epinephrine Inopressor ↑Contract ↑SVR Tachycardia, Arrhythmia & Invasive Ventilation Mechanical Circulatory Support Regional Care System References: Baselet B, Rombouts C, Benotmane AM, Baatout S, Aerts A. Cardiovascular diseases related to ionizing radiation: The risk of low-dose exposure (Review). International Journal of Molecular Medicine. 2016;38(6):1623-1641. doi:10.3892/ijmm.2016.2777. Bergmann, K. R., Kharbanda, A., & Haveman, L. (2015). Myocarditis And Pericarditis In The Pediatric Patient: Validated Management Strategies. Pediatric emergency medicine practice, 12(7), 1-23. Davies, P., & Maconochie, I. (2009). The relationship between body temperature, heart rate and respiratory rate in children. Emergency Medicine Journal, 26(9), 641-643. De Backer, D., et al. (2010). Comparison of dopamine and norepinephrine in the treatment of shock. New England Journal of Medicine, 362(9), 779-789. Ghelani, S. J., et al. (2012). Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circulation: Cardiovascular Quality and Outcomes, 5(5), 622- 627. Grogan, M., et al. (1995). Long-term outcome of patients with biopsy-proved myocarditis: comparison with idiopathic dilated cardiomyopathy. Journal of the American College of Cardiology, 26(1), 80-84. Imazio, M., et al. (2003). Cardiac troponin I in acute pericarditis. Journal of the American College of Cardiology, 42(12), 2144-2148. Imazio, M., et al. (2004). Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. Journal of the American College of Cardiology, 43(6), 1042-1046. Imazio, M., et al. (2007). Indicators of poor prognosis of acute pericarditis. Circulation, 115(21), 2739-2744. Kytö, V., Sipilä, J., & Rautava, P. (2014). Clinical Profile and Influences on Outcomes in Patients Hospitalized for Acute Pericarditis CLINICAL PERSPECTIVE. Circulation, 130(18), 1601-1606. - 5% hosp pts Levy, B., Perez, P., Perny, J., Thivilier, C., & Gerard, A. (2011). Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Critical care medicine, 39(3), 450-455. Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995; 333:269. O’Connell, J. B., & Topol, E. J. (1998). Diagnosis and medical treatment of inflammatory cardiomyopathy. Topol et al. Cardiovascular Medicine. Philadelphia: Lipincott-Raven. Rossello, X., et al. (2014). New electrocardiographic criteria to differentiate acute pericarditis and myocardial infarction. The American journal of medicine, 127(3), 233-239. van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., ... & Thiele, H. (2017). Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 136(16), e232-e268..