Download Diseases of the pericardium

Diseases of the pericardium
Pericarditis
• Pericardial inflammation may be due to infection,
immunological reaction ,trauma or neoplasm
and some time remained un explained.
• Pericarditis and Myocarditis often coexist.
• Causes :
• 1)Common ;Acute myocardial infarction ,viral (
e.g.Coxsacki B)
• 2)Less common : Uremia,malignant dis,Trauma
& connective tissue dis.
• 3)Rare : Bacterial infection ,rheumatic fever &
Tuberclosis.
Clinical features
• Pain is retrosternal with radiation to the
shoulders and neck and typically aggrevated by
deep breathing ,movement, a change of position
,exercise and swallowing.
• Low grade fever is common.
• A pericardial rub is a high pitched sound its
diagnostic, often heared in systole and may be
in diastole.(to –and –fro) quality.
• Investigations : The ECG show ST elevation with
up ward concavity over the affected area .Later
may be T inversion ,particularly if there is
associated myocarditis.
Management
• The pain can be relieved by asprin high dose but
a more potent anti-inflammatory agent such as
indomethacin may be required .
• Corticosteroid may suppress symptoms but not
healing.
• In viral pericarditis recovery usually occurs within
a few days or weeks.but there may be
recurrence .
• Purulent pericarditis require treatment with
antimicrobial therapy, paracentesis and if
necessary surgical drainage.
Pericardial Effusion
• Usually present with retrosternal oppression.its
difficult to be detected clinically.
• The heart sound become quiter.pericardial rub
abolished.
• The QRS voltage decreased.chest x-ray show
globular cardiomegaly.
• Echo.is diagnostic.
• Depending on aetilogy may be
fibrinous,serous,haemorraghic or purulent.
• A fibrinous exudates may eventually lead to
varying degree of adhesion.
• While serous pericarditis lead to a large effusion
of turbid, straw-colored fluid with a high protein
content.
• A haemorraghic effusion is often due to
malignancy particularly breast
cancer,Carcinoma of the bronchus and
lymphoma.
• Purulent pericarditis is rare and may occur as a
complication of septicaemia.
Cardiac tamponade
• It refer to acute heart failure due to
compression of the heart by a large or
rapidly developing effusion .Atypical
presentation occur when the effusion is
loculated as a result of previous
pericarditis or cardiac surgery.
Pericardial Aspiration
• Its also called pericardiocentesis, may be
indicated for diagnostic or therapeutic
purposes .
• It done by inserting a needle under xiphoid
process with direction toward left shoulder.
• Complications include Coronary artery
damage, bleeding and arrythmias.
The most common causes of acute
pericarditis:
A-Malignant neoplasm
B-Viral infection.
C-Bacterial.
Which one is false regarding treatment of
acute viral pericarditis:
A-May be self limitted disease and need no
treatment.
B-NSAID or high dose asprin is effective
treatment.
C-Steroid improve healing.
Regarding pericardial tamponade,which one
is not true:
A-Usually need no treatment.
B-Need urgent treatment.
C-May be a complication of car accident.
Tuberculosis Pericarditis
• May complicate pulmonary TB,but may be the first
manifestation of the disease.
• In Africa tuberculous effusion is a common manifestation
of AIDS.
• The condition typically present with chronic malaise
,weight loss and low grade fever.
• An effusion usually develops and the pericardium may
become thick and unyielding, leading to pericardial
constriction or tamponade.,an associated pleural
effusion is often present..
Management
• The diagnosis may be confirmed by
aspiration of the fluid and direct
examination or culture for tubercle bacilli.
• Treatment require specific anti TB,in
addition, a 3 month course of prednisolone
has been shown to improve out come.
Chronic Constrictive Pericarditis
• Is due to progressive thickening ,fibrosis &
calcification of the pericardium.
• In effect the heart encased in a solid shell
& can not work properly ,the calcification
may extend to the myocardium ,so affect
the myocardial function.
possible causes
1) Tuberculous pericarditis.
2) Haemopericardium .
3) viral pericarditis.
4) Rheumatoid arthritis.
5) purulent pericarditis.
Clinical Features
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Fatique.
Rapid low volume pulse.
Pulsus paradoxicus.
Elevated JVP (rapid y descent).
Kussmaul sign.
Loud early third sound(pericardial knock).
Hepatomegaly.
Ascitis & peripheral edema.
• The condition should be suspected in any
patient with un explained right sided failure and
a small heart.
• CXR show pericardial calcification,
echocardiography ,CT & MRI help for diagnosis.
• The differentiation of chronic constrictive
pericarditis from restrictive cardiomyopathy is
difficult and need complex echo-doppler studies
and cardiac catheterization.
Management
• Surgical resection of the diseased
pericardium can lead to dramatic
improvement in up to 50 % of cases.