By:Dawit Ayele MD,Internist. Acute Pericarditis Chronic Relapsing Pericarditis ...
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Pericardial DiseaseBy:Dawit AyeleMD,InternistAcute PericarditisChronic Relapsing PericarditisConstrictive PericarditisCardiac Tamponade
Pericardial DiseaseTwo major componentsserosa (viceral pericardium)mesothelial monolayerfacilitate fluid and ion exchangefibrosa (parietal pericardium)fibrocollagenous tissuePericardial Fluid15 - 50 ml of clear plasma ultrafiltrateLigamentous attachmentsto the sternum, vertebral column, diaphragmPericardial Anatomynot needed to sustain lifephysiologic functionslimit cardiac dilatationmaintain normal ventricular compliancereduce friction to cardiac movement barrier to inflammationlimit cardiac displacementPericardial PhysiologyContiguous spreadlungs, pleura, mediastinal lymph nodes, myocardium, aorta, esophagus, liverHematogenous spreadsepticemia, toxins, neoplasm, metabolicLymphangetic spreadTraumatic or irradiationPericardial Inflammationpathogenesisinflammation provokes a fibrinous exudate with or without serous effusionthe normal transparent and glistening pericardium is turned into a dull, opaque, and sandy saccan cause pericardial scarring with adhesions and fibrosisPericardial InflammationpathologyOutpatient settingusually idiopathicprobably 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 causesInpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post) Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder RadiationAcute Pericarditiscommon causesHistorysudden onset of anterior chest pain thatis pleuritic and substernalPhysical exampresence of two- or three-component rubECGmost important laboratory clueAcute PericarditisDiagnostic CluesCommon characteristicsretrosternal or precordial with raditaion to the neck, back, left shoulder or armSpecial characteristics (pericarditis)more likely to be *sharp and pleuritic with coughing, inspiration, swallowingworse by lying supine, relieved by sitting and leaning forwardChest Pain Historypericarditis vs infarctionPericardial friction rub is pathognomic for pericarditisscratching or grating soundClassically three components:presystolic rub during atrial fillingventricular systolic rub (loudest)ventricular diastolic rub (after A2P2)Heart Murmurs of PericarditisST-segment elevationreflecting epicardial inflammationleads I, II, aVL, and V3-V6lead aVR usually shows ST depressionST concave upward ST in AMI concave downward like a domePR segment depression (early stage)T-wave inversionoccurs after the ST returns to baselineAcute PericarditisECG features
Treat underlying causeAnalgesic agentscodeine 15-30 mg q 4-6 hrAnti-inflmmatory agentsASA 648 mg q 3-4 hrsNSAID (indomethacin 25-50 mg qid)Corticosteroids are symptomatically effective , but preferably avoidedAcute PericarditisManagementoccurs in a small % of patients with acute idiopathic pericarditissteroid dependency requiring gradual tapering over 3-12 months; NSAIDs, analgesics, and colchicine may be beneficialpericardiectomy for relief of symptoms is not always effectiveChronic Relapsing PericarditisDescribed by Dressler in 1956fever, 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 surgeryincidence of 6-25% treat with high-dose aspirinDresslers SyndromeAcute myocardial infarctionPulmonary embolismPneumoniaAortic dissection
Acute PericarditisDifferential Diagnosisrarely develop after an episode of acute idiopathic pericarditismore likely to develop after subacute pericarditis with effusion that evolve over several weeksmore frequent after purulent bacterial or tuberculous pericarditisConstrictive PericarditisIdiopathicradiotherapycardiac surgeryconnective tissue disordersdialysisbacterial infectionConstrictive PericarditiscausesIncidence of pericarditis in patients with pulmonary TB ranged from 1-8%Physical findings: fever, pericardial friction rub, hepatomegalyTB skin test usually positiveFluid smear for TB often negativePericardial biopsy more definitiveTuberculous PericarditisJugular veinsprominent X and Y descent with inspiration (Kussmauls sign)Lungs - possible pleural effusionHeart - diastolic pericardial knockAbdomen: ascites, pulsatile liverExtremities: peripheral edemaConstrictive Pericarditis Physical Findingsoften not recognized in its early phases by exam, x-ray, ECG, echotendency to overlook elevated JVPsubacute chronicdiastolic knock +++Kussmauls+++paradoxical pulse++++Constrictive PericarditisDiagnosisseroustransudative - heart failuresuppurativepyogenic infection with cellular debris and large number of leukocyteshemorrhagicoccurs with any type of pericarditisespecially with infections and malignanciesserosanguinousTypes of Effusive FluidChest x-rayusually requires > 200 ml of fluidcannot distinguish between pericardial effusion and cardiomeglyEchocardiographystandard for diagnosing pericardial effusionconvenient, highly reliable, cost effectivefalse positives (M-mode)- left pleural effusion, epicardial fat, tumor tissue, pericardial cystsDignostic Evaluationasymptomatic unless they are large enough to compress adjacent organsdysphagiacoughdyspneahoarsenesshiccupsabdminal fullnessnauseaNoncompressing EffusionDiffuse low voltageamount of fluidelectrical conductivity of the fluidElectrical alternansalternating amplitude of the QRSproduced by heart swinging motionalso seen in PSVT, HTN, ischemiaECG in Pericardial EffusionDecompensated cardiac compression from increased intracardaic pressCardiac TamponadeEarly stagemild to moderate elevation of central venous pressureAdvanced stage intrapericardial pressure ventricular filling, stroke volumehypotension impaired organ perfusionCardiac TamponadeDescribed in 1935 by thoracic surgeon Claude S. Beck3 features of acute tamponade Decline in systemic arterial pressureElevation in systemic venous pressure (e.g. distended neck vein)A small, quiet heartBecks TriadElevated jugular venous pressure Paradoxical pulseCardiac TamponadeBedside Diagnosisan exaggerated drop in blood pressure with inspiration (>10mmHg)tamponade without pulsusatrial septal defectaortic insufficiencyLVH with LVEDPpulsus without tamponadeCOPD, RV infarct, pulmonary embolism
Pulsus ParadoxusPericardial effusionhighly reliableCardiac tamponadeRA and RV diastolic collapsereduced chamber sizedistension of the inferior vena cavaexaggerated respiratory variation of the mitral and tricuspid valve flow velocitiesEchocardiographyDiagnostic tap usually not indicatedrarely have positive cytology or infection that can be diagnosedTherapeutic drainageindicated for significant elevation of the central venous pressure
PericardiocentesisBalloon dilatation of a needle pericardiostomysubxyphoid surgical pericardiostomyvideo-assisted thoracoscopy with localized pericardial resectionanterolateral thoracotomy with parietal pericardial resectionPericardial Window