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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
slide6
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

slide10
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
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.
pericardial fluid
Pericardial Fluid
  • 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
  • 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
  • Impaired diastolic filling of the chambers
  • Elevated systemic venous pressures
  • Reduced cardiac output
  • Dip and plateau curve on catheterization
constrictive pericarditis clinical
Constrictive PericarditisClinical
  • 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
slide36

Normal pericardium < 2 mm

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