PericarditiPericarditiss

DefinitionDefinition::

Is inflammation of pericardial layer of the heart. pericardial

layer covers the heart and protect it from any infection.

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

CausesCauses::I. Infection: is the most important cause:

C.Fugal InfectionD.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 pericardits 2nd ry to M.I in 3rd or 4th day of infection.(late presentation ).

Post pericardiotomy syndrome .auto immune self limiting disease affect pleura and pericardium .common af ter 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

ix. Radiation therpay .

Myocarditiscardiomyopathy

Clinical FindingClinical FindingDepond 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:ECG:

1/ Dry Pericarditis or 1/ Dry Pericarditis or Fibronous:Fibronous:

• 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 ( ( الساجد .وضع

• Fever: Arthralgia rigors, anxiaty and general weakness.

SymptomsSymptoms: :

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:Lab Finding:

1. CBC – leu kocytosis 20.000. increase sedmentation rate. Increase CRP

X-Ray:X-Ray:

Normal chest X-Ray. No signs of cardiac enlargement. No signs of pulmonary congestion.

ECHO:ECHO:

SymptomsSymptoms::• disapperance of cheast pain.

1. ECG changes - Flat T wave. - Low voltage ECG

2/ Precardial effusion without temponade:2/ Precardial effusion without temponade:

Signs: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:ECG:

Change in T wave not specific for P. effusion.

T wave flat or T wave inverted.Low voltage. Low QRS complex.

ECHO: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 DiagnosisDifferential Diagnosis

3rd heart sound. Normal heart sound. In the pericardial effusion there is distant heart sounds and apical impulse not visible.

Heart failure:

Complication of pericardial Complication of pericardial effusion:effusion:

1. Cardiac temponade2. Fibrosis: minimal effusion and this called

sero constrictive or sub acute inflammation.

Treatment of pericarditis without Treatment of pericarditis without effusion: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 Treatment of pericardial effusion:effusion:

1.Pericardio- synthesis: This is diagnostic and

therapeutic.

2. Thoracotomy: ( an open drainage).

3/ Cardiac Temponade: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:Symptoms:

Patients is unconscious, severly sweating, dizzness or may reach a circulatory shock.

- Increase venous pressure :

- Cardiac impulse: Are not palpable.

- Heart sound: Are distant and this is same as P. effusion.

Signs:Signs:

(Kussmaul’s sign). called inspiratory filling of superior vena cava.

ECG:ECG:

- Low voltage and T wave change.

- Non specific change.

ECHO:ECHO:

Is most helpful diagnotic method for cardiac tamponade.

Fluid inside between pericardium and posterior wall of ventride.

Invasive Method: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 DignosisDifferentia 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.

ECGECG::

Treatment:Treatment:

1. 1. pericardio syntheasis:pericardio syntheasis:

4. Constrictive 4. Constrictive PericarditsPericardits 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.

SymptomSymptoms:s: 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: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: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:ECG:

Non specific.

X-Ray:X-Ray:

Intraprecardial cacification

ECHO:ECHO:Absent of late diastolic filling.

D.DD.D

•Superior venacaval ospstruction.

•Restrective cardiomyopathy.

•Endomyocardial fibrosis.

Treatment:Treatment:

PericardiutomyPericardiutomy