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Forth stage
Medicine
(C.V.S)
Lec-1 9
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23/2/2016
PERICARDIAL DISEASES
ACUTE PERICARDITIS:
This is inflammation of the pericardium
May be
:( Types)
1. Fibrinous
2. Serous
3. Haemorrhagic
4.
Purulent
AETIOLOGY
May be idiopathic or secondary to
:
Viruses (coxsackie,flu,epstein-barr,mumps)
Bacteria (pneumonia,TB,staph,streps)
Fungi
MI
Drugs (penicillin,isoniazid,hydralazine,anti-neoplastic agents)
Others (uraemia,RA,SLE,myxoedema,malignancy,sarcoidosis
)
Clinical Features
The characteristic pain of pericarditis is retrosternal , radiates to the shoulders and
neck, and is typically aggravated by deep breathing, movement, a change of position,
exercise and swallowing.
A low-grade fever is common.
A pericardial friction rub is a high-pitched superficial scratching or crunching noise
produced by movement of the inflamed pericardium and is diagnostic of pericarditis;
It is usually heard in systole but may also be audible in diastole .
2
Investigations and management
The ECG shows:
1. ST elevation with upward concavity over the affected area, which may be
widespread.
2. PR interval depression is a very specific indicator of acute pericarditis.
3. Later, there may be T-wave inversion particularly if there is a degree of myocarditis.
The pain is usually relieved by aspirin (600mg 4-hourly) but a more potent anti-
inflammatory agent such as indomethacin (25mg 8-hourly) may be required.
Corticosteroids may suppress symptoms but there is no evidence that they
accelerate cure.
PERICARDIAL EFFUSION
Fluid in the pericardial sac
There is sometimes a sensation of retrosternal oppression.
An effusion is difficult to detect clinically. The heart sounds may become quieter,
although a pericardial friction is not always abolished.
Diagnosis
CXR (cardiomegaly)
ECG (small and low QRS complex and sometimes abnormal shaped)
ECHO (show an echo-free zone surrounding heart)
Treatment
Treat cause:
Pericardiocentesis (diagnostic for bacterial pericarditis and therapeutic
for cardiac tamponade)
Pericardial fluid (culture, ZN stain/TB culture , cytology)
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Constrictive Pericarditis
Meaning the heart is encased in a rigid pericardium.
Progressive thickening, fibrosis and calcification of the pericardium.
Cause is unknown but can be TB or after any pericarditis.
Clinical Features
Fatigue
Rapid, low-volume pulse
Pulsus paradoxus (excessive fall in BP during inspiration):
Sign of RHF
Kaussmaul sign (JVP increase w inspiration)
Quite heart sound
Hepatosplenomegaly
Ascites n oedema
Investigations and management
CXR (small heart)
CT and MRI (see pericardial calcification)
ECHO
Treatment: surgical incision!!
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Cardiac Tamponade
Accumulation of pericardial fluid with raised intra-pericardial P, so poor ventricular
filling, hence reduce C.O.
Causes include :
- Any pericarditis
- Aortic dissection
- Haemodylisis
- Warfarin
- Post cardiac biopsy
- Post cardiac cathetherization
Sign
- Tachycardia
- Drop BP
- Pulsus paradoxus
- JVP raised
- Kausmaul’s sign
- Muffled S1 n S2
Diagnosis
- Beck’s triad (fall BP, raised JVP, small n quiet heart)
- CXR can be cardiomegaly (if >250mL fluid)
- ECG low & small QRS complex
- ECHO (pericardial effusion, diastolic collapse of R atrium n R ventricle)
MANGMENT
Emergency Drainage
A.L.Y