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2 layered sac ( Visceral and Parietalis ) May contain 5 50 cc fluid Func : 1. Fixing the heart 2.

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:

Acute Subacute Chronic

(<6 weeks), (6 weeks to 6 months) (>6 months)

Classification : serous purulent fibrinous caseous hemorrhagic


(according to the composition of the inflammatory exudate)

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.

Most common causative organisms are Staphylococci, Streptococci, and Pneumococci.

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.

Usually organizes with or without calcification.

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

STEP Itests obligatory in all patients

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

Does not change the pain

Can increase the pain

Position

Pain is worse in the supine position or upon inspiration

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

STEP I tests obligatory in all patients

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

STEP I tests obligatory in all patients

Blood Analyses - ESR,CRP,LDH,Leukocytes - cTnI, CK-MB

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

Stage I : Diffuse STe + PR depression

Stage II : Return of ST segment + T wave flattening

Stage III : T wave inversion

Stage IV : T wave return upright

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

Pericardiosyntesis and Drainage


- For all patients : Diagnosis of viral, bacterial, tuberculous, fungal, drainage cholesterol and malignant pericarditis: Cytology, cell counts, Acid-fast bacilli staining cultures and PCR for M. tuberculosis Biochemical : specific gravity, protein level, glucose, LDH - Suspected TB : Adenosine deaminase, IFN-, pericardial lysozyme - suspected autoreactive or viral : PCR analyses for cardiotropic viruses - suspected bacterial or fungal : Cultures of pericardial fluid for aerobes, anaerobes and fungi (3), Blood cultures (3) - suspected chylopericardium : Cholesterol, triglycerides

STEP III Optional or if previous tests inconclusive

Pericardial/Epicardial Biopsy
- Histology (neoplastic and tuberculous pericarditis) - PCR for cardiotropic viruses, borreliosis and TB - Immunohistochemistry (autoreactive forms)

ESC 2008

Most common :

1. Myocard Infarction 2. Pulmonary embolism

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

Treatment & Prevention of recurrences

- 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

DIAGNOSIS & MANAGEMENT MAJOR PERICARD DISEASE Acute Pericarditis


Echocardiography
TAMPONADE PERICARDIOCENTESIS Or PERICARDIAL DRAINAGE PERICARDIECTOMY PERCUTANEUS BALLON PERICARDIOTOMY

Fluid

<20mm > 20mm

No TAMPONADE PE < 10mm

PE 10-20mm

PERICARDIOSCOPY & PERICARDIAL BIOPSY

INTRAPERICARDIAL THERAPY

Recurrent pericarditis

Cardiac Catheterization

Constrictive pericarditis

FOLLOW UP ECHOCARDIOGRAPHY

Effusive Constrictive pericarditis

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)

Classification Size of Effusion by Echocardiography


Small (echo free-space in diastole <10mm) 100cc* 2. Moderate (echo free-space in diastole 10-20mm) 100-250cc* 3. Large (echo free-space in diastole 20mm) >500cc*
1.
*Bonita echocardiography

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

Horowitz Classification by TM-Echocardiography


Type A normal motion of adjacent pericardial & endocardial layers Type B systolic separation of epicardial & pericardial layers Type C clear-cut systolic separation of epi - & pericardium Type D separation of both layers in systole & diastole Type E Thickened pericardium & endocardium without fluid separation Type F Residual fluid between thickened & concomitanly moving epi -& pericardial layers

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

A four-fold rise in serum antiviralantibody Levelssuggestive but not diagnostic

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).