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Pericardial Diseases. Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions Limits motion Prevents dilatation during volume increase Barrier to infection 15-50 ml serous fluid Well innervated. Acute Pericarditis Etiology. Infectious Viral Bacterial TB

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Pericardial diseases
Pericardial Diseases

  • Visceral – single layer mesothelial cells

  • Parietal- fibrous < 2 mm thick

  • Functions

    • Limits motion

    • Prevents dilatation during volume increase

    • Barrier to infection

  • 15-50 ml serous fluid

  • Well innervated


Acute pericarditis etiology
Acute Pericarditis Etiology

  • Infectious

    • Viral

    • Bacterial

    • TB

  • Noninfeccious

    • Post MI (acute and Dresslers)

    • Uremia

    • Neoplastic disease

    • Post radiation

    • Drug-induced

    • Connective tissue diseases/autoimmune

    • traumatic


Infectious
Infectious

  • Viral (idiopathic)

    • Echovirus, coxsackie B

    • Hepatitis B, influenza, IM, Caricella, mumps

    • HIV, TB

    • Bacterial (purulent)

      • Pneuococcus, staphlococci

      • fulminant


Pericarditis post mi
Pericarditis post- MI

  • Early <5% patients

  • Dressler’s 2 weeks – months

    • Autoimmune

  • Post-pericardiotomy


Neoplastic
Neoplastic

  • Breast

  • Lung

  • Lymphoma

  • Primary pericardail tumors rare

  • Hemmorrhagic and large


  • Radiation

    • Dose > 4000rads

    • Local inflammation

  • Autoimmune

    • SLE

    • RA

    • PSS (40% may develop)

  • Drugs-lupus like

    • Hydralazine

    • Procaimamide

    • Phenytoin

    • Methyldopa

    • Isoniazid

  • Drugs- not lupus

    • Minoxidil

    • Anthracycline antineoplastic agents


Pathogenesis and pathology
Pathogenesis and Pathology

  • Inflammatory

    • Vasodilation

    • Increased vascular permeability

    • Leukocyte exudation

  • Pathology

    • Serous-little cells

    • Serofibrinous – rough appearance / scarring

      • common

    • Purulent – intense inflammation

    • Hemmorrhagic – TB or malignancy


Clinical
Clinical

  • Chest pain

    • Radiate to back

    • Sharp and pleuritic

    • Positional – worse lying back

  • Fever

  • Dyspnea due to pleuritic pain


Chest pain in pericarditis
Chest pain in Pericarditis

• เจ็บบริเวณหลังต่อกระดูก sternum

• เจ็บมากเวลาหายใจ และเวลานอนหงาย

• เจ็บน้อยลงเวลาลุกนั่ง และ โน้มตัวไปด้านหน้า


Exam

  • Friction rub

    • Diaphragm leaning forward

    • 1, 2 or 3 components

      • Ventricular contraction, relaxaltion, atrial contraction

    • intermittent


Diagnostic
Diagnostic

  • Clinical history

  • ECG

    • Abn in 90%

    • Diffuse ST elevation

    • PR depression

  • Echocardiography

    • Effusion

  • PPD

  • Autoimmune antibodies

  • Evaluate for malignancy


(Circulation. 2006;113:1622-1632.)


Ekg in pericarditis
EKG in Pericarditis


(Circulation. 2006;113:1622-1632.)


Treatment
Treatment

  • ASA or NSAIDs

    • Avoid NSAID in MI

  • Colchicine

  • Steroids - avoid

    • May increase reoccurance

  • TB – Rx TB

  • Purulent – drainage of fluid + antibiotics

  • Neoplastic- drainage

  • Uremic - dialysis


Pericardial effusion
Pericardial Effusion

  • From any acute pericarditis

  • Hypothyriodism- increased capillary permeability

  • CHF- increased hydrostatic pressure

  • Cirrhosis- decreased plasma oncotic pressure

  • Chylous effusion- lymphatic obstruction

  • Aortic Dissection


Effusion pathophysiology
Effusion Pathophysiology

  • Pericardium is stiff- PV curve not flat

  • Above critical volume – rapid increase in pressure

  • Factors that determine compression

    • Volume

    • Rate of accumulation

    • Pericardial compliance


Clinical1
Clinical

  • Asymptomatic

  • Symptoms

    • CP, dyspnea, dysphagia, hoarseness, hiccups

  • Tamponade

  • Exam

    • Muffled heart sounds

    • Absence of rub

    • Ewarts sign-dullness L lung at scapula

      • atelectasis


Diagnostic studies
Diagnostic studies

  • CXR - > 250 ml fluid globular cardiomegaly

  • ECG low voltage and electrical alternans

  • Echocardiogram most helpful

    • Identify hemodynamic compromise



Treatment1
Treatment

  • If known cause- treat that

  • If unknown- may need pericardiocentesis or pericardial window

  • Cardiac tamponade is emergency- pericardiocentesis drainage or window


Tamponade
Tamponade

  • Any cause of effusion may lead to

  • Diastolic pressures elevate and = pericardial pressure

  • Impaired LV/RV filling

  • Increased systemic venous pressure

  • Decreased stroke volume and C.O.

  • Shock


Tamponade1
Tamponade

  • Have right side failure with edema and fatigue only if occurs slowly

  • Key physical findings:

    • JVD

    • Hypotension

    • Small quiet heart

  • Sinus tachycardia

  • Pulsus paradoxus- decease in BP > 10 during normal inspiration


Pulsus paradoxus
Pulsus Paradoxus

  • Exaggeration of normal

  • Normally septum moves toward LV with inspiration, with decrease in LV filling

  • With compression and fixed volume, there is even greater limitation in LV filling and reduced stroke volume

  • PP also seen in COPD/asthma


Tamponade2
Tamponade

  • Echocardiography

    • Compression of RV and RA in diastole

    • Can have localized effuison with localized compression of one chamber (RA,LV)

      • Effusion post cardiac surgery

    • Differentiate other causes of low cardiac output

  • Cardiac catheterization- definitive

    • Measure pressures- chamber and pericardial equal, and all elevated.



Lancet cardiac cycle2004; 363: 717–27


Pericardial fluid
Pericardial Fluid cardiac cycle

  • Stained and cultured

  • Cytologic exam

  • Cell count

  • Protein level

    • pp/sp> 0.5 - exudate

  • LDH level

    • p LDH/ s LDH > 0.6 - exudate

  • Adenosine Deaminase level - sensitive and specific for TB


Constrictive pericarditis
Constrictive Pericarditis cardiac cycle

  • Most common etiology is idiopathic (viral)

  • Any cause of pericarditis

  • Post cardiac surgery

  • Pathology

    • Organization of fluid, scarring, fusion of pericardial layers, calcification


Constrictive pericarditis1
Constrictive Pericarditis cardiac cycle

  • Impaired diastolic filling of the chambers

  • Elevated systemic venous pressures

  • Reduced cardiac output

  • Dip and plateau curve on catheterization


Constrictive pericarditis clinical
Constrictive Pericarditis cardiac cycleClinical

  • Symptoms

    • Fatigue, hypotension, tachycardia

    • JVD, hepatomegaly and ascites, edema

      • Can confuse with cirrhosis- look for JVD

  • Exam

    • Pericardial knock after S2- sudden cessation of ventricular diastolic filling

  • Kussmaul’s sign- JVD with inspiration

  • No pulsus paradoxus

  • Difficult to separate from restrictive cardiomyopathy- may need myocardial biopsy



Normal pericardium < 2 mm cardiac cycle

(Circulation. 2006;113:1622-1632.)


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