By:Dawit Ayele MD,Internist. Acute Pericarditis Chronic Relapsing Pericarditis Constrictive...

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Pericardial Disease By:Dawit Ayele MD,Internist

Transcript of By:Dawit Ayele MD,Internist. Acute Pericarditis Chronic Relapsing Pericarditis Constrictive...

Page 1: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Pericardial DiseaseBy:Dawit Ayele

MD,Internist

Page 2: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Acute Pericarditis Chronic Relapsing Pericarditis Constrictive Pericarditis Cardiac Tamponade

Pericardial Disease

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Two major components◦ serosa (viceral pericardium)

mesothelial monolayerfacilitate fluid and ion exchange

◦ fibrosa (parietal pericardium)fibrocollagenous tissue

Pericardial Fluid◦ 15 - 50 ml of clear plasma ultrafiltrate

Ligamentous attachments◦ to the sternum, vertebral column, diaphragm

Pericardial Anatomy

Page 4: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

not needed to sustain life physiologic functions

◦ limit cardiac dilatation◦ maintain normal ventricular compliance◦ reduce friction to cardiac movement ◦ barrier to inflammation◦ limit cardiac displacement

Pericardial Physiology

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Contiguous spread◦ lungs, pleura, mediastinal lymph nodes,

myocardium, aorta, esophagus, liver Hematogenous spread

◦ septicemia, toxins, neoplasm, metabolic Lymphangetic spread Traumatic or irradiation

Pericardial Inflammationpathogenesis

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inflammation provokes a fibrinous exudate with or without serous effusion

the normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac

can cause pericardial scarring with adhesions and fibrosis

Pericardial Inflammationpathology

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Outpatient setting◦ usually idiopathic◦ probably due to viral infections *Coxsackie A and B (highly cardiotropic) are the

most common viral cause of pericarditis and myocarditis

*Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV

Acute Pericarditiscommon causes

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Inpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post)

Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder

Radiation

Acute Pericarditiscommon causes

Page 9: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Historysudden onset of anterior chest pain thatis pleuritic and substernal

Physical exampresence of two- or three-component rub

ECGmost important laboratory clue

Acute PericarditisDiagnostic Clues

Page 10: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Common characteristics◦ retrosternal or precordial with raditaion to the

neck, back, left shoulder or arm Special characteristics (pericarditis)

◦ more likely to be *sharp and pleuritic◦ with coughing, inspiration, swallowing◦ worse by lying supine, relieved by sitting and

leaning forward

Chest Pain Historypericarditis vs infarction

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Pericardial friction rub is pathognomic for pericarditis

scratching or grating sound Classically three components:

◦ presystolic rub during atrial filling◦ ventricular systolic rub (loudest)◦ ventricular diastolic rub (after A2P2)

Heart Murmurs of Pericarditis

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ST-segment elevation◦ reflecting epicardial inflammation◦ leads I, II, aVL, and V3-V6◦ lead aVR usually shows ST depression

ST concave upward ◦ ST in AMI concave downward like a “dome”

PR segment depression (early stage) T-wave inversion

◦ occurs after the ST returns to baseline

Acute PericarditisECG features

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Treat underlying cause Analgesic agents

◦ codeine 15-30 mg q 4-6 hr Anti-inflmmatory agents

◦ ASA 648 mg q 3-4 hrs◦ NSAID (indomethacin 25-50 mg qid)◦ Corticosteroids are symptomatically effective , but

preferably avoided

Acute PericarditisManagement

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occurs in a small % of patients with acute idiopathic pericarditis

steroid dependency requiring gradual tapering over 3-12 months; NSAIDs, analgesics, and colchicine may be beneficial

pericardiectomy for relief of symptoms is not always effective

Chronic Relapsing Pericarditis

Page 18: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Described by Dressler in 1956 fever, pericarditis, pleuritis

(typically with a low grade fever and a pericardial friction rub)

occurs in the first few days to several weeks following MI or heart surgery

incidence of 6-25% treat with high-dose aspirin

Dressler’s Syndrome

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Acute myocardial infarction Pulmonary embolism Pneumonia Aortic dissection

Acute PericarditisDifferential Diagnosis

Page 20: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

rarely develop after an episode of acute idiopathic pericarditis

more likely to develop after subacute pericarditis with effusion that evolve over several weeks

more frequent after purulent bacterial or tuberculous pericarditis

Constrictive Pericarditis

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Idiopathic radiotherapy cardiac surgery connective tissue disorders dialysis bacterial infection

Constrictive Pericarditiscauses

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Incidence of pericarditis in patients with pulmonary TB ranged from 1-8%

Physical findings: fever, pericardial friction rub, hepatomegaly

TB skin test usually positive Fluid smear for TB often negative Pericardial biopsy more definitive

Tuberculous Pericarditis

Page 23: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Jugular veins◦ prominent X and Y descent◦ with inspiration (Kussmaul’s sign)

Lungs - possible pleural effusion Heart - diastolic pericardial knock Abdomen: ascites, pulsatile liver Extremities: peripheral edema

Constrictive Pericarditis Physical Findings

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often not recognized in its early phases by exam, x-ray, ECG, echo

tendency to overlook elevated JVPsubacute chronic

diastolic knock + ++Kussmaul’s + ++paradoxical pulse ++ ++

Constrictive PericarditisDiagnosis

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serous◦ transudative - heart failure

suppurative◦ pyogenic infection with cellular debris and

large number of leukocytes hemorrhagic

◦ occurs with any type of pericarditis◦ especially with infections and malignancies

serosanguinous

Types of Effusive Fluid

Page 26: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Chest x-ray◦ usually requires > 200 ml of fluid◦ cannot distinguish between pericardial

effusion and cardiomegly Echocardiography

◦ standard for diagnosing pericardial effusion◦ convenient, highly reliable, cost effective◦ false positives (M-mode)- left pleural

effusion, epicardial fat, tumor tissue, pericardial cysts

Dignostic Evaluation

Page 27: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

asymptomatic unless they are large enough to compress adjacent organs◦ dysphagia◦ cough◦ dyspnea◦ hoarseness◦ hiccups◦ abdminal fullness◦ nausea

Noncompressing Effusion

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Diffuse low voltage◦ amount of fluid◦ electrical conductivity of the fluid

Electrical alternans◦ alternating amplitude of the QRS◦ produced by heart swinging motion◦ also seen in PSVT, HTN, ischemia

ECG in Pericardial Effusion

Page 29: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Decompensated cardiac compression from increased intracardaic press

Cardiac Tamponade

Page 30: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

Early stage◦ mild to moderate elevation of central venous

pressure Advanced stage

◦ intrapericardial pressure ventricular filling, stroke volume

◦ hypotension ◦ impaired organ perfusion

Cardiac Tamponade

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Described in 1935 by thoracic surgeon Claude S. Beck

3 features of acute tamponade ◦ Decline in systemic arterial pressure◦ Elevation in systemic venous pressure (e.g.

distended neck vein)◦ A small, quiet heart

Beck’s Triad

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Elevated jugular venous pressure Paradoxical pulse

Cardiac TamponadeBedside Diagnosis

Page 33: By:Dawit Ayele MD,Internist.  Acute Pericarditis  Chronic Relapsing Pericarditis  Constrictive Pericarditis  Cardiac Tamponade.

an exaggerated drop in blood pressure with inspiration (>10mmHg)

tamponade without pulsus◦ atrial septal defect◦ aortic insufficiency◦ LVH with LVEDP

pulsus without tamponade◦ COPD, RV infarct, pulmonary embolism

Pulsus Paradoxus

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Pericardial effusion◦ highly reliable

Cardiac tamponade◦ RA and RV diastolic collapse◦ reduced chamber size◦ distension of the inferior vena cava◦ exaggerated respiratory variation of the mitral

and tricuspid valve flow velocities

Echocardiography

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Diagnostic tap◦ usually not indicated◦ rarely have positive cytology or infection that can

be diagnosed Therapeutic drainage

◦ indicated for significant elevation of the central venous pressure

Pericardiocentesis

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Balloon dilatation of a needle pericardiostomy

subxyphoid surgical pericardiostomy video-assisted thoracoscopy with localized

pericardial resection anterolateral thoracotomy with parietal

pericardial resection

Pericardial Window