17/03/2023
PERICARDITIS IN HORSES
Brian S. Burks, DVM
Diplomate, ABVP
Board Certified Equine Specialist
Pericarditis is inflammation of the membranous sac in which the heart is contained- the pericardium. It may lead to pericardial effusion- fluid and/or fibrin buildup within the sac. Infectious causes include bacterial, viral, and possibly mycoplasma infections. These infections most often are spread hematogenously (via the blood) or extend from the endocardium, myocardium, or lungs. Pericarditis may also be parasitic, neoplastic, or traumatic in origin. Many cases of pericardial effusion are idiopathic. Sterile, inflammatory, and eosinophilic effusions have been recognized. A number of years ago, an outbreak of pericarditis was found in Kentucky, associated with a caterpillar vector. Actinobacillus spp. were associated with the heart. Traumatic cases may be from rib fractures that puncture the pericardium, or from penetrating foreign bodies, including metal, wood, and plant stems. These may pe*****te the thorax directly or migrate from the stomach or duodenum. Pericarditis is most usually effusive, although fibrinous, and even constrictive pericarditis may also develop.
Clinical findings associated with pericarditis are associated with its effects on the heart and cardiac displacement. This leads to a triad of signs: a weak, rapid pulse; muffled heart sounds; and venous hypertension. Other findings include fever, pericardial friction rub (like creaking leather), cardiac murmur, jugular pulsation, edema, weight loss, anorexia, and depression. Pericardial friction rubs are only evident early in the course of disease since fluid distention of the pericardial sac prevents further rubbing. Edema and jugular distention are due to the compromise of the right side of the heart; systemic arterial pressure is maintained since the left heart is more robust, which enhances formation of ventral edema. Later, cardiac tamponade (compression) may result in continuous distention of the jugular veins, without pulsation. The capillary refill time is prolonged, and the distal extremities are cool, indicating compromise of the peripheral circulation.
Clinical signs are those of congestive heart failure, although the myocardium is normal, including fever, lethargy, depression, anorexia, tachypnea, ventral edema, colic, and weight loss. Pericardial effusion causes tamponade and reduced cardiac filling.
Diagnostic evaluation includes laboratory studies, radiography, electrocardiography, and echocardiography. Usual findings include anemia, hyperproteinemia, and hyperfibrinogenemia. Cardiac troponin I and CK-MB enzymes may be elevated in cases of pericarditis or myocarditis and are thus not specific. Thoracic radiographs may show an enlarged, globoid cardiac silhouette, and enlarged pulmonary vessels. Pulmonary infiltrates and pleural effusion may also be present. The ECG shows altered electrical activity that is often not specific for pericarditis. A regular, repeating change in the morphology of the P, QRS, and T waves is pathognomonic for pericarditis. It occurs due to regular movement of the heart within the pericardial fluid.
Echocardiographic examination is the best non-invasive diagnostic modality, as fluid is within the pericardial sac. Fibrin tags are often visible; extensive fibrin production is possible, though uncommon, possibly due to the constant motion of the heart. There may be collapse of the right ventricle or atrium, indicating cardiac tamponade. Up to 12 liters of fluid may be present, causing cardiac tamponade and respiratory embarrassment. Pleural effusion may also be noted. The position of the heart can also be determined. Typically, the pericardium is thickened, the chambers are small, and there is reduced fractional shortening and exuberant movement of the ventricular septum.
Pericardiocentesis (tap of the sac) allows further diagnostic studies. This is often achieved by entering the pericardial sac with an intravenous. Continuous drainage or drainage of thick fluid may be accomplished via a chest tube. The fluid should be analyzed for total protein and white blood cells. Evaluation helps differentiate septic, aseptic, and neoplastic processes. Fluid should also be submitted for culture and sensitivity testing. Streptococcus spp. are the most common isolates, but Actinobacillus equuli, Pseudomonas aeruginosa, Pasteurella spp., and Mycoplasma felis have all been isolated. Viral diseases most encountered include equine influenza, equine viral arteritis or equine herpesvirus-1 abortion may be associated with these viruses.
Treatment of pericarditis varies, depending upon cause and the clinical situation. Broad-spectrum intravenous antibiotic therapy is indicated while waiting for culture and sensitivity results. Pericardiocentesis and drainage are always appropriate with significant fluid. Drainage should be slow to prevent cardiac collapse. The procedure is performed ultrasound guided with ECG monitoring and IV access. Pericardial lavage may be necessary to prevent or remove excessive fibrin formation. It may also remove inflammatory cells, immune complexes, and viral particles. Several liters of warmed intravenous fluid can be slowly instilled into the pericardial space, and then drained. Antibiotics may also be placed directly into the cavity to allow extremely high local levels. Intravenous, broad spectrum antibiotics are indicated, such as penicillin and an aminoglycoside. Non-steroidal anti-inflammatory drugs (NSAID) or corticosteroids are used to treat inflammation, controlling the rate of fluid accumulation.
In cases where constrictive pericarditis has developed, surgery may be indicated. A band of thick, fibrous tissue may surround the heart, causing compression and compromise of cardiac function. This band may be cut by thorascopic techniques and is commonly employed in humans. The tissue forms on the pericardium and the epicardium, and directly on the surface of the heart. Fortunately, this is not common in horses.
Historically, the prognosis for pericarditis has been considered poor, but, more recently, successful outcomes have been reported. Death may occur in a matter of days, weeks, or months; however, with aggressive treatment, many horses return to athletic function, including cases I have treated. Repeated lavage and early treatment with broad spectrum antibiotics have greatly improved the outcome of this disease.
Pericarditis may result in myocarditis and congestive heart failure (CHF). Clinical signs include weight loss, exercise intolerance, coughing, tachypnea, ventral edema, ascites, pleural effusion, and colic-like signs. The jugular veins have pathologic distention and pulsation. There may be moist bronchovesicular sounds, as well as crackles. Clinical signs may vary depending on which, or both sides of the heart are involved. Congestive heart failure may be left or right sided, but often is biventricular. Most commonly, CHF is from valvular disease, especially the pulmonic and tricuspid valves. Therefore, murmurs are common over the right hemithorax. Arrhythmias, especially atrial fibrillation, are also common with CHF.
Echocardiography allows the determination of irreversible structural cardiac disease. These include ruptured chordae tendineae, severe valvular degeneration, myocardial fibrosis, dilated cardiomyopathy (enlarged heart), and congenital defects. Cardiac contractility can also be measured.
Treatment of CHF includes diuretic medication and those used to increase the contraction of the heart. Treatment of the underlying cause is necessary.
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(724) 727-3481
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