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PericarditisPericarditis
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DefinitionDefinition::
Is inflammation of pericardial layer of the heart. pericardial layer covers the
heart and protect it from anyinfection.
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A . Viral infection: this is the most important cause in infection coxachi A virus.
A nd B commonest one. B3 , B5.ECHO virus, influenza V. hepatitis V.
B. Bacterial infection Tubercle bacilli
Staphylo coccus
Strepto coccus
Pneumo coccus
CausesCauses::I. Infection: is the most important cause:
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C.Fugal Infection
D.Parasitic InfectionThose causes same as the causes of myocordotis and so the patient with
acute myocarditis can present withpericarditis and vice versa that thedisease could start in the myocardium
and spread to the pericardium.
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II. Hyper sensitively reaction.
Follow myocardial infarctiondressler syndrome ).post
pericardits 2nd
ry to M.I in 3rd
or 4th day of infection.(latepresentation ).
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Post pericardiotomy syndrome .auto
immune self limiting disease affect pleuraand pericardium .common after cardiacsurgery specially mitral valve ³mitralcomissuratomy´
Serum sickness and drug reaction as(hydralazine)
III. Direct and indirect wound as
stab wound .
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Iv.Metabolic disorders as uraemia. (most
important). Present with pericaditiseffusion and espically after introduction of renal dialysis .Thepericardial effusion enhanced after renal dialysis .
v.Myxedema.vi.Malignancy like lymphoma.
vii.Aortic dissection + myocardialinfection.
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viii. Cobalt pear cardiomyopathy. Pear can.Lead to
ix. Radiation therpay .
Myocarditiscardiomyopathy
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Clinical FindingClinical FindingDepond on the:
- Type of inflammation.
- Sevirety of inflammation.
- Formation of pericardial fluid.
1. Dry pericarditis.
2. Percardial effusion without cardiac temponade.
3. Cardiac temponade.
4. Pericardial constriction.
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ECG:ECG:
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1/ Dry Pericarditis or Fibronous:1/ Dry Pericarditis or Fibronous:
Chest pain:
It is precardial, sever, radiate to shoulder, so mimic theacute myocardial infraction pain. But the pain of pericarditis increase intensity with inspiration or lyingflat and improve when standing or sit down or leaningforward ( ) .
Fever: A rthralgia rigors, anxiaty and general weakness.
Symptoms:Symptoms:
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Signs:
Pericardial rub: Is the harsh sound continuousatrail systole, Ventricular systole and ventriculardiastole. It is superficial sound has no relation toheart sound. Nearly periodical area. and easy to
heard when the patient hold its breathing soyou should differentiate between pleural rub andpericardial rub. Pleural rub might be heardduring inspiration. Pericardial rub start todisappear when effusion develops. A ndpericardial pain improve.
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Lab Finding:Lab Finding:
1. CBC leu kocytosis 20.000.
increase sedmentation rate.
Increase CRP
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XX--Ray:Ray:
Normal chest X-Ray.
No signs of cardiac enlargement.
No signs of pulmonary congestion.
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ECHO:ECHO:
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SymptomsSymptoms:: disapperance of cheast pain.
1. ECG changes - Flat T wave.
- Low voltage ECG
22 / Precardial effusion without temponade: / Precardial effusion without temponade:
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Signs:Signs:
- Blood pressure normal.
- Pulse normal.
-Only heart sound become distant.
- Invisible cardiac pulse.
- Pericardial rub might disappear orit may remain and this indicationto previous pericarditis so no pain
and no rub.
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ECG:ECG:
Change in T wave not specific for P. effusion.
T wave flat or T wave inverted.
Low voltage. Low QRS complex.
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ECHO:ECHO:
It is 99% diagnostic to pericardial effusion.
ECHO: Showed free area between
pericardium and posterior wall of L.ventricle.
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The ECHO not useful in early stage of dry
pericarditis but in late when there isfibrosis.
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Differential DiagnosisDifferential Diagnosis
3rd heart sound. Normal heart
sound. In the pericardialeffusion there is distant heart sounds and apical impulse not
visible.
Heart failure:
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Complication of pericardial effusion:Complication of pericardial effusion:
1. Cardiac temponade
2. Fibrosis:
minimal effusion and this called seroconstrictive or sub acute inflammation.
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Treatment of pericarditis without effusion:Treatment of pericarditis without effusion:
1. Salicylate NSID in high dose.
2. Bed Rest.
most patient respond to those points. If patient after 10 day of starting salicylate orNSIDrugs if still have signs or symptoms of pericarditis corticosteroids can be added
but role of corticosteroids is doubt if start from beginning of the disease.
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Treatment of pericardial effusion:Treatment of pericardial effusion:
1. Pericardio- synthesis:This is diagnostic and therapeutic.
2. Thoracotomy:( an open drainage).
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33 / Cardiac Temponade: / Cardiac Temponade:
In Temponade the amount of fluid inside pericardial sacis increased. When intra pericardial pressure equal to thediastolic pressure in the heart. ( the right vertical or right
atrial pressure) then temponade develops. The right side of the heart has less diastolic pressure
than left side of the heart and for that reason the cardiactemponade compress right side of the heart because thepressure reach to diastolic pressure of right ventricle or
right atrium before reach to left ventricle and so allpatients present with right side heart failure heart problem.
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Symptoms:Symptoms:
Patients is unconscious, severly sweating,dizzness or may reach a circulatory shock.
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- Increase venous pressure :
- Cardiac impulse: A re not palpable.
- Heart sound: A re distant and this is same as P. effusion.
Signs:Signs:
(Kussmauls sign). called inspiratory filling of superior vena cava.
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ECG:ECG:
- Low voltage and T wave change.
- Non specific change.
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ECHO:ECHO:
Is most helpful diagnotic method forcardiac tamponade.
Fluid inside between pericardium andposterior wall of ventride.
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Invasive Method:Invasive Method:
Abscent.Y Descend:C.Tamponede the diastolic pressure in thepericardial sac equal to diastolic pressure in Rt ventricle and so there is interference with thefilling of Rt ventricle and so absent of Y descent.For that reason it is an acute emergency we
would remove fluid to give chance to Rt ventricleto dilate.
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Differentia DignosisDifferentia Dignosis
From severly P. Emblism or acutemyocardial infraction or any acute
emergency state. Type of pain is similar
But pain of pericardial when lying flat.
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ECGECG::
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Treatment:Treatment:
11.. pericardio syntheasis:pericardio syntheasis:
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4. Constrictive Pericardits4. Constrictive Pericardits
There is sero constrictive andconstrictive pericarditis. The differencebetween them, that the sero contrictive
affect Rt pericardium + minimal fluid inpericardiuml so we called it seroconstrictive or sub acute type.
In constrictive pericarditits, wholepericardium is thickened and fibrosis somake thick fibrous layer around heart.
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Symptoms:Symptoms:
Is swelling of abdomen and lowerlimb as it mimic presentation asacute Rt heart failure.
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Dyspnea is minmal in constrictive
pericarditis is not presenting symptom but it can occur.
A naroxia.
General weakness + wasting.
In constrictive pericarditis, the history of previous attack of pericarditis is important.
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Signs:Signs:
- Low blood pressure.- Pulsus paradoxus:
Is present in constrictive pericarditis andcardiac tamponade and abscent inpericardial effusion without tamponadeand in dry pericarditis.
- (it is change in sytolic blood pressure
more than 10 mm of Hg during insiration).
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-
Arrythmia:( A trail Fibrillation) in 30% in constrictivepericarditis ( one of causes of artailfibrillation is constrictive pericarditis) high
jaqular venous pressure.
- No deep Y wave descent :
This opposite to constrictive pericarditiswhen there is Y wave (deep descent).
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Rigt hypocondrial pain:Rigt hypocondrial pain:
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But in constrictive dilated Rt ventricle at early diastolic rapidy and there is Y rapiddescent until the pressure inside Rt ventricle equal to whole distolic pressure
in the pericardium so there is squair root phenomena.
Percardial knock:
A scitis:
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ECG:ECG:
Non specific.
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XX--Ray:Ray:
Intraprecardial cacification
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ECHO:ECHO:
A bsent of late diastolic filling.
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D.DD.D
Superior venacaval ospstruction.
Restrective cardiomyopathy.
Endomyocardial fibrosis.
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Treatment:Treatment:
PericardiutomyPericardiutomy