CURSO DE POSTGRADO
2009
DR. ENRIQUE COURCELLES
“El pericardio es una suave t
ú
nica lisa
que envuelve alcoraz
ó
n y que contiene una
peque
ñ
a cantidad de l
í
quido parecido a la
orina”
Hip
ó
crates, 460 AC
ETIOLOGÍA DE LA PERICARDITIS
Viral
Tuberculosa
Bacteriana
Otras (sífilis, parásitos)
INFECCIOSA
HIPERSENSIBILIDAD
Enferm. del colágeno*
Secundario a drogas
Post IAM (Dressler
*
)
NO INFECCIOSA
Idiopática*
Neoplasia / metástasis
*
Insuficiencia renal
Traumática*
Hipotiroidismo
Post pericardiectomia*
Infarto de miocardio
Quilopericardio
Post irradiación
* Pericarditis recidivante
(1)
(2)
(3)
Diagnostic criteria for acute pericarditis
and
myopericarditis
in the
clinical setting
Acute pericarditis
(at least 2 criteria of 4 should be present)*:
1. Typical chest pain (síntoma)
2. Pericardial friction rub (signología)
3. Suggestive ECG changes (typically widespread ST segment elevation) (ECG)
4. New or worsening pericardial effusion (ECHO)
Myopericarditis:
1. Definite diagnosis of acute pericarditis, PLUS
2. Suggestive symptoms (dyspnea, palpitations, or chest pain) and ECG abnormalities beyond
normal variants, not documented previously (ST/T abnormalities, supraventricular or ventricular
tachycardia or frequent ectopy, atrioventricular block), OR focal or diffuse depressed LV function
of uncertain age by an imaging study
3. Absence of evidence of any other cause
4. One of the following features: evidence of elevated cardiac enzymes (creatine kinase-MB
fraction, or troponin I or T), OR new onset of focal or diffuse depressed LV function by an
imaging study, OR abnormal imaging consistent with myocarditis (MRI with gadolinium,
gallium-67 scanning, anti-myosin antibody scanning)
Case definitions for
myopericarditis
include
:
Suspected myopericarditis
: criteria 1 plus 2 and 3
Probable myopericarditis:
criteria 1,2,3, and 4
Confirmed myopericarditis:
hystopathologic evidence of myocarditis by endomyocardial biopsy
or on autopsy.
PERICARDITIS AGUDA. ETIOLOGÍA
Imazio M. 1996-2004 453 pacientes
Idiopático:
377 ( 83.2%)
Etiología específica:
76 (16.8%)
Neoplásica: 23 (5.1%)
Tuberculosa: 17 (3.8%)
Autoinmune: 33 (7.3%)
Purulenta: 3 (0.7%)
PRESENTACIÓN CLINICA DE LAS ENF.
DEL PERICARDIO
• Pericarditis aguda fibrinosa
• Derrame pericárdico sin compromiso hemodinámico
• Taponamiento cardíaco
PERICARDITIS AGUDA
PACIENTES DE ALTO RIESGO
QUE NECESITAN INTERNACIÓN
•Síntomas subagudos (días o semanas)
•Fiebre alta (38°C) + leucocitosis
•Evidencias que sugieran taponamiento
•Derrame pericárdico importante ( >20 mm )
•Inmunodeprimidos
•Pacientes anticoagulados
•Traumatismo de torax
•Falta de respuesta a AINES durante 7 días
TAPONAMIENTO PERICÁRDICO
Elevación de la presión yugular
Hipotensión arterial
Disminución de la presión de pulso
Pulso paradojal
Congestión pulmonar moderada
Precordio tranquilo
Cambios en el ecg
Eco (+)
Etiología: idiopático
post quirúrgico
urémico
tuberculoso
purulento
neoplásico
Rapidez
Rapidez
Rapidez
Rapidez de
de
de producci
de
producci
producci
producci
ó
n
nn
n
Presi
Presi
Presi
Presi
ó
n
nn
n intraperic
intraperic
intraperic
intraperic
á
rdica
rdica
rdica
rdica
Taponamiento
Taponamiento
Taponamiento
Taponamiento
P/V en el derrame pericárdico
A: derrame hiperagudo
B: derrame subagudo
C: derrame subagudo
D: derrame cr
ó
nico
aspiraci
aspiraci
aspiraci
aspiraci
ó
n
nn
n
Volume curves recorded from data acquired during pericardiocentesis. Curve A (in red) plots data from a patient with hyperacute tamponade that followed laceration of a coronary artery during an angioplasty-stenting procedure. Note the extreme elevation of pericardial pressure and that withdrawal of only 100 ml, half the volume we could aspirate, lowered the pressure to 10 mmHg. Curve B (in blue) plots data from a patient who had a history of prior pericarditis, assumed to be of viral etiology. Subsequently he developed a chronic pericardial effusion that reached at least 1500 ml in volume. At the time of presentation to our service, the jugular venous pressure was 22 mmHg. Aspiration of 300 ml of pericardial fluid reduced the pericardial pressure to 10 mmHg, and removing another 600 ml achieved a nearly normal pericardial pressure. Aspiration of the remaining large effusion did not affect pericardial pressure. The curves of cases of intermediate acuity or chronicity would fall between these two extremes. Courtesy of Ralph Shabetai MD.
TAPONAMIENTO PERICÁRDICO
ESP.TAAo
Resp
TA
Flujo
Hemodynamics in cardiac tamponade
The M-mode through the minor axis in a patient with an anterior and posterior pericardial effusion and tamponade is seen in panel A; during inspiration, the right ventricle (RV) fills and the left ventricle (LV) becomes smaller; during expiration, the opposite occurs. In the graph in panel B, RV (RVEDd) and LV end diastolic diameters (LVEDd) are plotted against one another and demonstrate a negative correlation, a result of reciprocation of the chambers within the pericardium. Since the pericardium is a rigid box, as respiration brings more blood into the RV, there is less room in the LV; blood pools in the inflating lungs during inspiration. This blood plus the increased stroke volume sent to the lungs during RV inspiratory expansion reaches the lLV during expiration. As the LV expands, the RV is compressed. During RV expansion underfilling of the LV results in a drop in pulse pressure perceived as the paradoxical pulse.
ECG EN LA PERICARDITIS CON DERRAME
alternancia eléctrica
↑
ST
↓PR
↓↓↓↓
voltaje
↓T
alternancia eléctrica
bamboleo eléctrico
PERICARDITIS AGUDA
Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment elevations seen best here in leads II, III, aVF, and V3 to V6. There is also subtle PR segment deviation (positive in aVR, negative in most other leads). ST segment elevation is due to a ventricular current of injury associated with epicardial
inflammation; similarly, the PR segment changes are due to an atrial current of injury which, in pericarditis, typically displaces the PR segment upright in lead aVR and downward in most other leads. Courtesy of Ary Goldberger, MD
.
•Myocardial ischemia or infarction
•Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute
takotsubo cardiomyopathy)
•Acute myocardial infarction (MI)
•Post-MI (ventricular aneurysm pattern)
•Previous MI with recurrent ischemia in the same area
•Acute pericarditis
•Normal "early repolarization variants"
•Left ventricular hypertrophy or left bundle branch block (only V1-V2 or
V3)
•Other
•Myocarditis (may look like myocardial infarction or pericarditis)
•Brugada patterns (V1-V3 with right bundle branch block-appearing
morphology)
•Myocardial tumor
•Myocardial trauma
•Hyperkalemia (only leads V1 and V2)
•Hypothermia (J wave/Osborn wave)
Adrenal insufficiency
Anasarca
Artifactual or spurious, eg, unrecognized standardization of ECG
at one-half the usual gain (ie, 5 mm/mV)
Cardiac infiltration or replacement (eg, amyloidosis, tumor)
Cardiac transplantation, especially with acute or chronic
rejection
Cardiomyopathy, idiopathic or secondary*
Chronic obstructive pulmonary disease
Constrictive pericarditis
Hypothyroidism, usually with sinus bradycardia
Left pneumothorax (mid-left chest leads)
Myocardial infarction, extensive
Myocarditis, acute or chronic
Normal variant
Obesity
Pericardial effusion
Pericardial tamponade, usually with sinus tachycardia
Pleural effusions
CAUSAS DE BAJO VOLTAJE EN EL
QRS
CRITERIOS ECOCARDIOGRÁFICOS DEL
TAPONAMIENTO CARDÍACO
•Colapso de la AD al final de la diástole
•Cambios recíprocos del VI y VD en relación con la
respiración (VD>VI en inspiración)
•Aumento de la variacion respiratoria en la velocidad de
flujo en las valvulas Mi y Tricusp.
Inferior vena cava during respiration in a normal subject
The subcostal view in a normal subject shows the inferior
vena cava (IVC).
Left panel
: Prior to inspiration, the normal
diastolic IVC diameter (arrows) is less than 20 mm.
Right
panel
: During inspiration, the IVC collapses to less than 50
percent of its original diameter.
Inferior vena cava during respiration in tamponade
Panel A
: The subcostal view of the inferior vena cava (IVC) in a
patient with tamponade. The IVC is plethoric measuring over 20
mm in diameter.
Panel B
: During inspiration, the IVC diameter
fails to decrease. There is a large pericardial effusion (PE)
surrounding the right atrium (RA).
Cardiomegalia por radiología
Ecocardiografia transtoráxica
> 1 cm liquido
Taponamiento?
0.5-1.0 cm líquido
sin compromiso hemodinámico
< 0.5 cm líquido o
no líquido
Observación clínica
Repetir eco en 1-2 semanas
Sospecha de pericarditis
Infecciosa o maligna
Observación clínica
Repetir eco en 1-7 dias
pericardiocentesis
Consulta urgente con
cardiólogo
Considerar pericardiocentesis
diagnóstica o terapéutica
CARDIOMEGALIA VS. DERRAME PERICÁRDICO
Anterior Posterior