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Pericardial Disease Diagnostic & Management
Pericardial Disease Diagnostic & Management
2. limiting cardiac distension 3. limiting infection from lung Normal pericardial thickness (2 mm)
Inflammation the pericardium Most common presentation of pericardial disease Self limiting disease which responsive to oral anti-inflammation Adult>child , men>women Most common cause : Viral & Idiopathic
Clinically:
Serous pericarditis : > This form usually consists of 50 to 200 ml of slowly accumulating exudates > nonbacterial involvement - rheumatic fever, - systemic lupus erythematosus, - tumours, - uremia and - primary viral infection (Eg. Coxsackie)
Purulent pericarditis : Composed of 400 to 500 ml of a thin to creamy pus with erythematous, granular serous surfaces Due to bacteria, fungus or parasitic infection. Infection reaches by - Direct extension Hematogenous - Lymphatic route Eg. In Pneumonia, empyema, lung abscess, subphrenic abscess, liver abscess etc or during cardiotomy.
Fibrinous pericarditis :
The most common clinical form, seen in myocardial infarct with a pericardial friction rub Exudate may be completely resolved or be organized causing adhesive pericarditis
Caseous pericarditis : This form is due to tuberculosis (by direct extension from neighbouring lymphnodes) or less commonly, mycotic infection. This type most frequently, causes fibrocalcific constrictive pericarditis.
Hemorrhagic pericarditis: This is composed of an exudates of blood admixed with fibrinous to suppurative effusion.
Most commonly following cardiac surgery or is associated with tuberculosis or malignancy.
Infection 1. Idiopathic and Viral Pericarditis 2. Tuberculous pericarditis 3. Non-TB bacterial pericarditis (purulent) Non-Infection 4. Pericarditis following Myocardial Infarction 5. Uremic pericarditis 6. Neoplastic pericarditis 7. Radiation induced pericarditis 8. Connective tissue disorder associated pericarditis 9. Drug induced pericarditis
Chest Pain : sharp & positional - relieved by sitting up and bending forward - worsened by lying down (supine position) and inspiration Fever, palpitation, cough, dyspneu, history of viral prodrome
Auscultation : Pericard friction rub (mono- /bi- /triphasic) Other : patient in distress, positional chest pain, diaphoresis & heart failure
ESC 2008
Characteristic/ Parameter
Pericarditis
Sharp, pleuritic , retro-sternal (under the sternum) or left precordial (left chest) pain
Myocardial infarction
Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
Pain description
Radiation
Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation.
Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion
Position
Not positional
Onset/duration
Sudden or chronically worsening Sudden pain, that lasts for hours or pain that can come and go in sometimes days before a patient comes paroxysms or it can last for hours to the ER before the patient decides to come to the ER
Consists of 3 sounds: one systolic, and two diastolic. The systolic sound may occur anywhere in systole and the two diastolic sounds occur at the times when the ventricles are stretched. This stretching occurs in early diastole and at the end of diastole High in frequency and best heard with the diaphragm. best heard at the LLSB with the patient leaning forward or lying supine in deep expiration
ECG (important contribution on diagnostic) - ST-Elevation with/out reciprocal ST-depression - PR depression (common in pericarditis) Echocardiography -Trans-esophageal echocardiography (TEE) -Trans-thoracic echocardiography (TTE) in oesophageal probing is not feasible or in high suspicion of aortic dissection and high blood pressure, - Effusion type B-D (Horowitz) - Sign of tamponade Xray Waterbottle (if Pericardial effusion is present) Holter monitor* - Depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium
ESC 2008
Generally laboratory values are normal, Uremic pericarditis : BUN Creatinin Myocardial infarction (heart attack): Troponin (I, T) , CK-MB , Myoglobin , and LDH1
ECG
ACUTE PERICARDITIS
PR depression
ST elevation
Netter Cardiology
early
days
2 weeks
STEP II mandatory in tamponade, in large (> 20 mm) effusions and in suspected purulent, tuberculous or neoplastic aetiology, or if previous tests were inconclusive in symptomatic patients resistant to conventional treatment
Pericardial/Epicardial Biopsy
- Histology (neoplastic and tuberculous pericarditis) - PCR for cardiotropic viruses, borreliosis and TB - Immunohistochemistry (autoreactive forms)
ESC 2008
Most common :
Points to differ :
- Previous symptomp - Variation with position/respiration - Nausea or diaphoresis - Typical of chest pain (stabbing / pressure)
Symptomatic :
- Exercise restriction - Hospitalization - Pain managements : NSAID (Ib) Ibuprofen (300-800mg tid-qid) Aspirin (300-600mg every 4-6h) Indomethacine not recommended for elderly (reduction of coronary flow) - Provide GI protection
- Colchicine (0.5mg bid) - Class IIa - Percutaneus ballon pericardiotomy - Class IIb - Corticosteroids - in poor general condition only prednison 1-1,5mg/kg (1month) tappered off - Pericardiectomy - in frequent & highly symptomatic resistant to medical treatment
Fluid
PE 10-20mm
INTRAPERICARDIAL THERAPY
Recurrent pericarditis
Cardiac Catheterization
Constrictive pericarditis
FOLLOW UP ECHOCARDIOGRAPHY
S Y M P T O M A T I C
Chronic PE (2Yr)
Clinical Presentation : Venous Pressure , Pulsus Paradoksus, Hypotension, Tachycardia, dyspneu Precipitating Factors : Drugs ( cyclosporine, anticoagulant, thrombolitics ) Recent cardiac surgery, Indwelling supplementation Blunt chest trauma Malignancy Connective tissue disease Renal failure Septicemia ECG : non spesific ( ST-T change, electrical alternan QRS ) Xray : Enlarged cardiac silhouette with clear lungs field Echo : Diastolic collapse RV free wall, RA collapse, LA and rarely LV collapse.
Etiology : - increased capilary permeability (severe hypothyroidism), - Increased capilary hidrostatic pressure (CHF) - decreased plasma oncotic pressure (cirrhosis / nephrotic syndrome) - Lymphatic obstruction of pericardial drainage (neoplasm or TB)
Pericardial Effusion
Pericardial Effusion
Pericardial Effusion
Definition clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Etiology Cardiac tamponade can occur due to: End-stage lung cancer / neoplastic Pericarditis caused by bacterial or viral inf. Heart attack (acute MI) Heart surgery Wounds to the heart Dissecting aortic aneurysm (thoracic)
Any etiology of acute pericarditis can lead to cardiac tamponade Patophysiology : Increasing pressure presses on the heart Forces the septum to bend into the left ventricle venous return is restricted. (systemic and pulmonary venous pressure rise) Decreased stroke volume. This causes obstructive shock to develop.
Anxiety , restlessness Chest pain o Radiating to the neck, shoulder, back, or abdomen o Sharp, stabbing o Worsened by deep breathing or coughing Difficulty breathing Discomfort, sometimes relieved by sitting upright or leaning forward Fainting , light-headedness Pale, gray, or blue skin Palpitations Rapid breathing Swelling of the abdomen or other areas
Classical cardiac tamponade presents three signs, known as Beck's Triad. 1. Hypotension 2. Jugular-venous distension 3. Muffled heart sounds Pulsus Paradoxical (Blood pressure may fall when the person inhales deeply) Kussmauls sign (increase JVP during inspiration) Breathing may be rapid (faster than 12 breaths in an adult per minute) Heart rate may be over 100 (normal is 60 to 100 beats per minute) Heart sounds faint during examination with a stethoscope Neck veins may be abnormally extended (distended) but the blood pressure may be low Peripheral pulses may be weak or absent Chest fullness and discomfort Hint: look to diagnostic tests to identify
Echocardiogram is the first choice to help establish the diagnosis Chest CT or MRI of chest Chest x-ray Coronary angiography ECG
Initial treatment supportive for example administration of oxygen and monitoring. Initial management in hospital is > Hemodynamically stable (Pericardial Effusion) = resolve spontaneously or with NSAIDs, observation > Hemodynamically instable (SBP<90mmHg, pulsus paradoxus>10mmHg, effusion>20mm, RV collapse) Immediate drainage Pericardiocentesis or emergency pericardial window Treat cause IV fluid, medication to maintain BP
Recurrent effusion Organ hypoperfusion (renal failure) Effusive-constrictive pericarditis if left untreated then cardiac arrest may occur (in which case the presenting rhythm is likely to be pulseless electrical activity)
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Constrictive Pericarditis
Clinical Syndrome impaired expansion of the heart by a rigid, chronically inflammed /thickened pericardium Symptoms : Fatique, peripheral oedema, breathlessness, abdominal swelling Decompensated Patients : venous congestion, hepatomegaly, pleural effusions, ascites
Differential Diagnosis : Cardiac tamponade, Restrictive cardiomyopathy, pulmonary embolism, RV Infarction, pleural effusion, COPD
Constrictive Pericarditis
CT scan/MRI is superior superior to echocardiography in the assessment of pericardial anatomy and thickness.
Constrictive Pericarditis
Constrictive Pericarditis
Constrictive Pericarditis
Constrictive Pericarditis
The only effective treatment of severe constrictive pericarditis is surgical removal of the pericardium. Symptoms and signs of constriction may not resolve immediately
Symptomatic drugs (diuretics, digitalis, beta blockers)
Antituberculous tuberculous constriction Complications : acute cardiac insufficiency, ventricular wall rupture
Viral Pericarditis
The most common infection of pericardium
Etiology : entero-, echo-, adeno-, cytomegalo-, EpsteinBarr, herpes simplex, influenza, parvo B19, hepatitis C, Human Immunodeficiency Viruses (HIV), etc
Treatment
Treatment applied to eradicate the virus 1. Cytomegalovirus : hyperimmunoglobulin 2. Coxsackie B : interferon or 3. Adenovirus & parvovirus : immunoglobulin
HIV pericarditis manifestation result of infective or non infective/neoplastic disease (kaposi sarcoma, lymphoma)
1. Acute pericarditis is most often of idiopathic or viral cause and is usually a self-limited illness. 2. Common findings in acute pericarditis include (a) pleuritic chest pain; (b) fever; (c)pericardial friction rub; and (d) diffuse ST-segment elevation on the ECG, often accompanied by PR segment depression. 3. Complications of pericarditis include cardiac tamponade (accumulation of pericardial fluid under high pressure, which compresses the cardiac chambers) and constrictive pericarditis (restricted filling of the heart because of surrounding rigid pericardium).