Pericardial diseases

Transcription

1 Pericardial diseases Anatomy of the pericardium Consists of parietal and visceral membranes. The space between them(pericardial space is normally filled by a lymph like fluid. The fluid s normal quantity is ml. This lubricates the surface of the heart.

2 Functions of the pericardium Prevents sudden dilatation of the cardiac chambers. Facilitates atrial filling. Fixes the heart in it s position. Retards the spread of infection from surrounding structures.

3 Acute pericarditis Etiological classification 1. Infectious pericarditis. 2. Non-infectious pericarditis 3. Pericarditis related to autoimmune diseases

4 Infectious pericarditis 1. Viral coxaci B, mumps, echovirus,hiv 2. Pyogenic Pnumococcal,Stphylococcal, Neisseria, 3. Tuberculous 4. Fungal Histoplasma, Coccidomycosis, 5. Others - Syphilitic, protozoal, parasitic Candida

5 Non infectious pericarditis 1. Acute myocardial infarction 2. Chronic renal failure 3. Neoplasm (Primary and secondary) 4. Hypothyroidism 5. Trauma 6. Post-irradiation 7. Familial Mediterranean fever 8. Idiopathic

6 Pericarditis due to hypersensitivity 1. Rheumatic fever 2. Collagen vascular diseases SLE, RA, PAN 3. Drugs procainamide, hydralazine, INH 4. Post cardiac injury Post myocardial infarction (Dressler s syndrome) Post trauma Post surgery

7 1. Fever Clinical Manifestations 2. Generalized prostration 3. Pain: Stabbing Sever Retrosternal and left precordial Radiates to left shoulder and back Aggravated by breathing coughing and change in posture. Improves by leaning forward and increased by lying flat

8 4. Pericardial friction rub: High pitched superficial leathery sound. Usually systolic, might be heard also in diastole, sometimes have three components per cardiac cycle. Best heard if the diaphragm is applied firmly on the left lower sternal border Variable in intensity and may be intermittent. Its absence doesn't exclude the Dx.

9 Electrocardiography Widespread elevation of the ST segment. The ST segment have an upward concavity. There is no significant Q wave changes. After few days the ST segment retunes to normal. After the ST segment returns to normal the T wave becomes inverted.

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11 ECG Changes Myocardial Infarction Acute Pericarditis ST elevation, convex upward Usually localized May be reciprocal changes ST elevation, Q wave T wave inversion may be together ST elevation, concave upward Usually diffused No reciprocal changes Start ST elevation back normal T wave inversion No pathological Q wave May be PR segment depression

12 ST ELEV

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14 Treatment Bed rest Specific treatment if the causative agent is recognized as in TB. Non-steroidal antiinflammatory drugs: Aspirin 900 mg. qid Indomethacine mg. qid Steroids - Prednisolon mg.\day

15 Pericardial effusion And cardiac temponade Fluid may accumulate in the pericardial space after any type of pericarditis. If it reaches a degree that impedes the normal inflow of blood into the ventricles, it is called Cardiac temponade. Cardiac temponade is fatal if not recognized and treated promptly.

16 Causes Neoplastic diseases Idiopathic pericarditis Chronic renal failure Bleeding Surgery Trauma Anticoagulant

17 Clinical features Severity depends not only on the amount of the accumulated fluid, but also on the rapidity of accumulation. So the amount of fluid necessary to produce temponad may be as little as 200cc, to as much as 2 liters

18 Clinical features Dyspnea Weakness Palpitation Rapid thready pulse Pulsus paradoxus JVP is elevated Cardiac apical impulse is not palpable Quiet heart sounds

19 Electrocardiography May be normal Usually low voltage May show evidence of pericarditis Some times QRS voltage my vary from beat to beat (QRS alternance)

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21 Chest X - Ray Enlarged cardiac silhouette Flask shape heart

22 Echocardiography Definitive diagnosis Fluids in the pericardial space Ventricular filling is impeded

23 Treatment Every patient with evidence of pericarditis should be admitted to detect this grave complication. If there is only evidence of effusion, then continue treatment as pericarditis. If there is evidence of temponade, then Pericardiocentesis should be done immediately.

24 Chronic constrictive pericarditis It results when the healing of an acute fibrinous or serofibrinous pericarditis is followed by obliteration of the pericardial cavity with granulation tissue firm scar encasing the heart calcification.

25 Causes It can follow any type of pericardial injury. Usual causes are: TB pericarditis Heamopericardium Viral pericarditis Purulent pericarditis Idiopathic

26 Clinical features Symptoms and signs of systemic venous congestion are the hallmark of constrictive pericarditis

27 Clinical features Fatigue Rapid, small volume pulse, st. irregular Pulsus paradoxus Elevated JVP Kaussmal s sign Loud early 3 rd. Heart sound Hepatomegaly Ascitis Peripheral edema Weight loss Minimum dyspnea No Orthopnea

28 Electrocardiography Non specific Low voltage Sometimes atrial fibrillation

29 Chest X ray Small cardiac silhouette pericardial calcification

30 Echocardiography Diagnostic

31 C-T scan and MRI

32 Treatment Conservative Bed rest Salt restriction Diuretics Anti Tb Surgery Dramatic improvement Carries a high mortality