Download pericarditis

Pericardial Disease
By Dr. Muhammad Aftab Shah
Senior Registrar Cardiology
KEMU/Mayo Hospital, Lahore.
1
Pericardial Disease
•
•
•
•
•
Acute Pericarditis
Chronic Relapsing Pericarditis
Constrictive Pericarditis
Cardiac Tamponade
Localized and Low Pressure
Tamponade
• Restrictive Cardiomyopathy
2
Pericardial Anatomy
• Two major components
– serosa (viceral pericardium)
mesothelial monolayer
facilitate fluid and ion exchange
– fibroa (parietal pericardium)
fibrocollagenous tissue
• Pericardial Fluid
– 15 - 50 ml of clear plasma ultrafiltrate
• Ligamentous attachments
– to the sternum, vertebral column, diaphragm
3
9/98
medslides.com 4
Pericardial Physiology
• 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
5
Pericardial Inflammation
pathogenesis
• Contiguous spread
– lungs, pleura, mediastinal lymph nodes,
myocardium, aorta, esophagus, liver
• Hematogenous spread
– septicemia, toxins, neoplasm, metabolic
• Lymphangetic spread
• Traumatic or irradiation
6
9/98
medslides.com 7
Pericardial Inflammation
pathology
• 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
8
PERICARDITIS
9
Acute Pericarditis
common causes
• 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, varicellazoster, influenza, Epstein-Barr, HIV
10
Acute Pericarditis
common causes
• Inpatient setting
T = Trauma, TUMOR
U = Uremia
M = Myocardial infarction (acute, post)
Medications (hydralazine, procain)
O = Other infections (bacterial, fungal, TB)
R = Rheumatoid, autoimmune disorder
Radiation
11
Acute Pericarditis
Diagnostic Clues
• History
sudden onset of anterior chest pain that
is pleuritic and substernal
• Physical exam
presence of two- or three-component rub
• ECG
most important laboratory clue
12
Chest Pain History
pericarditis vs infarction
• Common characteristics
– retrosternl 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
13
Heart Murmurs of Pericarditis
• 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)
14
Acute Pericarditis
ECG features
• 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
15
16
17
18
Acute Pericarditis
Management
• 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
19
Types of Effusive Fluid
• 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
20
Dignostic Evaluation
• 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
21
Noncompressing Effusion
• asymptomatic unless they are large
enough to compress adjacent organs
–
–
–
–
–
–
–
dysphagia
cough
dyspnea
hoarseness
hiccups
abdminal fullness
nausea
22
Cardiac Tamponade
• Decompensated cardiac compression
from increased intracardaic press
23
Cardiac Tamponade
• Early stage
– mild to moderate elevation of central
venous pressure
• Advanced stage
–  intrapericardial pressure
 ventricular filling,  stroke volume
– hypotension
– impaired organ perfusion
24
Beck’s Triad
• 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
25
Cardiac Tamponade
Bedside Diagnosis
• Elevated jugular venous pressure
• Paradoxical pulse
26
Pulsus Paradoxus
• 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
27
Echocardiography
• 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
28
Pericardiocentesis
• 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
29