Download Pericarditis

Pericarditis
Definition:
Is inflammation of pericardial layer of
the heart. pericardial layer covers the
heart and protect it from any
infection.
Causes:
I. Infection: is the most important cause:
A. Viral infection: this is the most important
cause in infection coxachi A virus.
And B commonest one. B3 , B5.
ECHO virus, influenza V. hepatitis V.
B. Bacterial infection – Tubercle bacilli
Staphylo coccus
Strepto coccus
Pneumo coccus
C.Fugal Infection
D.Parasitic Infection
Those causes same as the causes of
myocordotis and so the patient with
acute myocarditis can present with
pericarditis and vice versa that the
disease could start in the myocardium
and spread to the pericardium.
II. Hyper sensitively reaction.
• Follow myocardial infarction
dressler syndrome ).post
nd
rd
pericardits 2 ry to M.I in 3
th
or 4 day of infection.(late
presentation ).
Post pericardiotomy syndrome .auto
immune self limiting disease affect pleura
and pericardium .common after cardiac
surgery specially mitral valve “mitral
comissuratomy”
Serum sickness and drug reaction as
(hydralazine)
III. Direct and indirect wound as
stab wound .
Iv.Metabolic disorders as uraemia. (most
important). Present with pericaditis
effusion
and
espically
after
introduction of renal dialysis .The
pericardial effusion enhanced after
renal dialysis .
v. Myxedema.
vi.Malignancy like lymphoma.
vii.Aortic dissection + myocardial
infection.
viii. Cobalt pear cardiomyopathy. Pear can.
Lead to Myocarditis
cardiomyopathy
ix. Radiation therpay .
Clinical Finding
Depond 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.
ECG:
1/ Dry Pericarditis or Fibronous:
Symptoms:
• Chest pain:
It is precardial, sever, radiate to shoulder, so mimic the
acute myocardial infraction pain. But the pain of
pericarditis increase intensity with inspiration or lying
flat and improve when standing or sit down or leaning
forward (‫ (وضع الساجد‬.
• Fever:
Arthralgia rigors, anxiaty and general weakness.
Signs:
Pericardial rub: Is the harsh sound continuous
atrail systole, Ventricular systole and ventricular
diastole. It is superficial sound has no relation to
heart sound. Nearly periodical area. and easy to
heard when the patient hold it’s breathing so
you should differentiate between pleural rub and
pericardial rub. Pleural rub might be heard
during inspiration. Pericardial rub start to
disappear when effusion develops. And
pericardial pain improve.
Lab Finding:
1. CBC – leu kocytosis 20.000.
increase sedmentation rate.
Increase CRP
X-Ray:
 Normal chest X-Ray.
 No signs of cardiac enlargement.
 No signs of pulmonary congestion.
ECHO:
2/ Precardial effusion without temponade:
Symptoms:
• disapperance of cheast pain.
1. ECG changes - Flat T wave.
- Low voltage ECG
Signs:
- Blood pressure normal.
- Pulse normal.
- Only heart sound become distant.
- Invisible cardiac pulse.
- Pericardial rub might disappear or
it may remain and this indication
to previous pericarditis so no pain
and no rub.
ECG:
Change in T wave not specific for P. effusion.
T wave flat or T wave inverted.
Low voltage.
Low QRS complex.
ECHO:
• It is 99% diagnostic to pericardial effusion.
• ECHO: Showed free area between
pericardium and posterior wall of L.
ventricle.
• The ECHO not useful in early stage of dry
pericarditis but in late when there is
fibrosis.
Differential Diagnosis
Heart failure:
3rd heart sound. Normal heart
sound.
In
the
pericardial
effusion there is distant heart
sounds and apical impulse not
visible.
Complication of pericardial effusion:
Cardiac temponade
2. Fibrosis:
1.
minimal effusion and this called sero
constrictive or sub acute inflammation.
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 or
NSIDrugs 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.
Treatment of pericardial effusion:
1. Pericardio- synthesis:
This is diagnostic and therapeutic.
2. Thoracotomy:
( an open drainage).
3/ Cardiac Temponade:
• In Temponade the amount of fluid inside pericardial sac
•
is increased. When intra pericardial pressure equal to the
diastolic 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 cardiac
temponade compress right side of the heart because the
pressure reach to diastolic pressure of right ventricle or
right atrium before reach to left ventricle and so all
patients present with right side heart failure heart
problem.
Symptoms:
Patients is unconscious, severly sweating,
dizzness or may reach a circulatory shock.
Signs:
- Increase venous pressure :
(Kussmaul’s sign). called inspiratory filling of
superior vena cava.
- Cardiac impulse:
Are not palpable.
- Heart sound:
Are distant and this is same as P. effusion.
ECG:
- Low voltage and T wave change.
- Non specific change.
ECHO:
Is most helpful diagnotic method for
cardiac tamponade.
Fluid inside between pericardium and
posterior wall of ventride.
Invasive Method:
Abscent.Y Descend:
C.Tamponede the diastolic pressure in the
pericardial sac equal to diastolic pressure in Rt
ventricle and so there is interference with the
filling 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 ventricle
to dilate.
Differentia Dignosis
• From severly P. Emblism or acute
myocardial infraction or any acute
emergency state.
• Type of pain is similar
But pain of pericardial when lying flat.
ECG:
Treatment:
1.
pericardio syntheasis:
4. Constrictive Pericardits
There is sero constrictive and
constrictive pericarditis. The difference
between them, that the sero contrictive
affect Rt pericardium + minimal fluid in
pericardiuml so we called it sero
constrictive or sub acute type.
In constrictive pericarditits, whole
pericardium is thickened and fibrosis so
make thick fibrous layer around heart.
Symptoms:
Is swelling of abdomen and lower
limb as it mimic presentation as
acute Rt heart failure.
• Dyspnea is minmal in constrictive
pericarditis is not presenting symptom but
it can occur.
• Anaroxia.
• General weakness + wasting.
• In constrictive pericarditis, the history of
previous attack of pericarditis is important.
Signs:
- Low blood pressure.
- Pulsus paradoxus:
Is present in constrictive pericarditis and
cardiac tamponade and abscent in
pericardial effusion without tamponade
and in dry pericarditis.
- (it is change in sytolic blood pressure
more than 10 mm of Hg during insiration).
- Arrythmia:
(Atrail Fibrillation) in 30% in constrictive
pericarditis ( one of causes of artail
fibrillation is constrictive pericarditis) high
jaqular venous pressure.
- No deep Y wave descent :
This opposite to constrictive pericarditis
when there is Y wave (deep descent).
Rigt hypocondrial pain:
• But in constrictive dilated Rt ventricle at
early diastolic rapidy and there is Y rapid
descent until the pressure inside Rt
ventricle equal to whole distolic pressure
in the pericardium so there is squair root
phenomena.
• Percardial knock:
• Ascitis:
ECG:
Non specific.
X-Ray:
Intraprecardial cacification
ECHO:
Absent of late diastolic filling.
D.D
• Superior venacaval ospstruction.
• Restrective cardiomyopathy.
• Endomyocardial fibrosis.
Treatment:
Pericardiutomy