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PERICARDIAL DISEASES BY Nusrum Iqbal MD NORMAL FUNCTIONS OF THE PERICARDIUM •Visceral(serous) and parietal (fibrous)pericardium •seperated by a small amount of fluid (15-50ml) •prevents sudden dilatation of cardiac chambers during exercise and with hypervolemia •facilitates atrial filling during systole •restricts anatomic position of the heart •minimize friction between heart and surrounding structure •prevents displacement of the heart and kinking of great vessels PERICARDIAL DISEASES ACUTE PERICARDITIS PERICARDIAL EFFUSION CARDIAC TEMPONADE CHRONIC CONSTRICTIVE PERICARDITIS OTHERS •Pericardial cyst •tumors ACUTE PERICARDITIS •Most common pathologic process involving the pericardium •may be classified clinically or etiologically •Clinically, Effusive (serous or sanguineous) and Fibrinous •Duration less than 6 weeks ETIOLOGY •COMMON •acute myocardial infarction •viral (coxackie B, but often not identified) •LESS COMMON •bacterial infection (staphyllococcus/H.influenzae) •uremia •malignant disease •trauma •connective tissue disease (e.g.SLE) •RARE •rheumatic fever •tuberculosis CLINICAL FEATURES •Chest pain (substernal and sharp) •history of upper respiratory tract infection •pericardial friction rub •fever INVESTIGATIONS ECG •ST segment elevation, concave upwards, in all leads facing epicardial surface •later, T wave inversion •changes persist for sometime CARDIAC ENZYMES •may be elevated if there is associated myocarditis ECHOCARDIOGRAPHY Treatment •Anti-inflammatory drugs such as ASPIRIN, naproxen or indomethacine •Complete Bed rest •Corticosteroid if severe or recurrent PERICARDIAL EFFUSION •Acute pericarditis is initially dry and fibrinous •Almost all etiologies of Acute pericarditis also induce the formation of pericardial effusion •It is important if it collects in a short period of time •Effusion collects in the closed pericardial sac and can lead to cardiac tamponade CLINICAL FEATURES •Chest pain •obscures the apex beat •heart sounds are soft and distant •friction rub can be heard initially but disappear once fluid accumulates INVESTIGATIONS ECG •low voltages CHEST X-RAY •large globular heart with sharp outline ECHOCARDIOGRAPHY •gold standard test and most effective CARDIAC TAMPONADE •Cardiac temponade is a medical emergency •accumulation of fluid in the pericardium sufficient to cause serious obstruction to the inflow of blood to the ventricles •this condition is fatal if not recognized and treated promptly Causes neoplasia, idiopathic pericarditis, uremia tuberculosis, hemopericardium, trauma CLINICAL FEATURES •Dyspnea, orthopnea, hepatic engorgement •Hypotension •Raised jugular venous pressure with sharp diastolic collapse, y descent (Friedrich’s sign) •paradoxical pulse (fall of systolic blood pressure with inpiration) •increased neck vein distension with inspiration (kussmaul’s sign) rare •widening of the area of cardiac dullness Investigations ECG •low voltage •electrical alternans of the P, QRS, and T waves CHEST X-RAY •enlagement of the cardiac silhoutte •relatively clear lung fields ECHOCARDIOGRAPHY RIGHT HEART CATHETERIZATION •equalization of pressures in all the chambers Treatment Observation if the effusion is small and free of signs and symptoms Pericardiocentesis •immediately if tamponade •it is also indicated if malignant, tuberculous or a purulent pericarditis is suspected pericardial fenestration (pericardial window) •for reaccumulation of the effusion CONSTRICTIVE PERICARDITIS •A slowly progressive fibrosis of the pericardium develops and constricts the movement of the heart, so that it cannot expand in diastole •fibrous tissue is dense and inelastic •calcification is common •inflow to the heart is impeded, so that the cardiac out is diminished and systemic venous pressure is raised ETIOLOGY •Tuberculosis is the most important cause •hemopericardium •bacterial infection •rheumatic heart disease •following acute pericarditis CLINICAL FEATURES •Fatigue •exsercise intolerance •Typical signs of systemic venous congestion •ascites •dependent edema •hepatosplenomegaly •jugular venous distension •kussmaul’s sign •friedrich’s sign •pulsus paradoxus •atrial fibrillation •pericardial knock (an early loud third heart sound) INVESTIGATIONS CHEST X-RAY •relative small heart with obvious calcification ECG •low voltage and T wave inversion ECHOCARDIOGRAM •Thickened pericardium with relatively immobility of the heart •ventricular cavaties are small with normal wall thickness CT SCAN CARDIAC CATHETERIZATION AND MRI •for difficult cases TREATMENT Surgical removal is the treatment of choice Thanks
