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Pericardial Disease

Pericardial Disease. Pericardial Disease. Acute Pericarditis Chronic Relapsing Pericarditis Constrictive Pericarditis Cardiac Tamponade Localized and Low Pressure Tamponade Restrictive Cardiomyopathy. Pericardial Anatomy. Two major components

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Pericardial Disease

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  1. Pericardial Disease medslides.com

  2. Pericardial Disease • Acute Pericarditis • Chronic Relapsing Pericarditis • Constrictive Pericarditis • Cardiac Tamponade • Localized and Low Pressure Tamponade • Restrictive Cardiomyopathy medslides.com

  3. Pericardial Anatomy • Two major components • serosa (viceral pericardium)mesothelial monolayerfacilitate fluid and ion exchange • fibroa (parietal pericardium)fibrocollagenous tissue • Pericardial Fluid • 15 - 50 ml of clear plasma ultrafiltrate • Ligamentous attachments • to the sternum, vertebral column, diaphragm medslides.com

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  5. Pericardial Physiology • not needed to sustain life • physiologic functions • limit cardiac dilatation • maintain normal ventricular compliance • reduce friction to cardiac movement • barrier to inflammation • limit cardiac displacement medslides.com

  6. Pericardial Inflammationpathogenesis • Contiguous spread • lungs, pleura, mediastinal lymph nodes, myocardium, aorta, esophagus, liver • Hematogenous spread • septicemia, toxins, neoplasm, metabolic • Lymphangetic spread • Traumatic or irradiation medslides.com

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  8. Pericardial Inflammationpathology • inflammation provokes a fibrinous exudate with or without serous effusion • the normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac • can cause pericardial scarring with adhesions and fibrosis medslides.com

  9. PERICARDITIS medslides.com

  10. Acute Pericarditiscommon causes • Outpatient setting • usually idiopathic • probably due to viral infections • Coxsackie A and B (highly cardiotropic) are the most common viral cause of pericarditis and myocarditis • Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV medslides.com

  11. Acute Pericarditiscommon causes • Inpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post) Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder Radiation medslides.com

  12. Acute PericarditisDiagnostic Clues • History sudden onset of anterior chest pain that is pleuritic and substernal • Physical exam presence of two- or three-component rub • ECG most important laboratory clue medslides.com

  13. Chest Pain Historypericarditis vs infarction • Common characteristics • retrosternl or precordial with raditaion to the neck, back, left shoulder or arm • Special characteristics (pericarditis) • more likely to be sharp and pleuritic •  with coughing, inspiration, swallowing • worse by lying supine, relieved by sitting and leaning forward medslides.com

  14. Heart Murmurs of Pericarditis • Pericardial friction rub is pathognomic for pericarditis • scratching or grating sound • Classically three components: • presystolic rub during atrial filling • ventricular systolic rub (loudest) • ventricular diastolic rub (after A2P2) medslides.com

  15. Acute PericarditisECG features • ST-segment elevation • reflecting epicardial inflammation • leads I, II, aVL, and V3-V6 • lead aVR usually shows ST depression • ST concave upward • ST in AMI concave downward like a “dome” • PR segment depression (early stage) • T-wave inversion • occurs after the ST returns to baseline medslides.com

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  19. Acute PericarditisManagement • Treat underlying cause • Analgesic agents • codeine 15-30 mg q 4-6 hr • Anti-inflmmatory agents • ASA 648 mg q 3-4 hrs • NSAID (indomethacin 25-50 mg qid) • Corticosteroids are symptomatically effective , but preferably avoided medslides.com

  20. Chronic Relapsing Pericarditis • occurs in a small % of patients with acute idiopathic pericarditis • steroid dependency requiring gradual tapering over 3-12 months; NSAIDs, analgesics, and colchicine may be beneficial • pericardiectomy for relief of symptoms is not always effective medslides.com

  21. Dressler’s Syndrome • Described by Dressler in 1956 • fever, pericarditis, pleuritis(typically with a low grade fever and a pericardial friction rub) • occurs in the first few days to several weeks following MI or heart surgery • incidence of 6-25% • treat with high-dose aspirin medslides.com

  22. Acute PericarditisDifferential Diagnosis • Acute myocardial infarction • Pulmonary embolism • Pneumonia • Aortic dissection medslides.com

  23. Case Study 1 A 56-year-old man develops recurrent chest discomfort 5 days after an anterior myocardial infarction, which was managed initially with tissue plasminogen activator. The pain is sharp and positional, radiating toward both clavicles. It is different from the pain associated with his infarction. medslides.com

  24. Case Study 1 Physical Exam:AfebrileNo pericardial friction rubECG: mild PR depression in lead 2no significant change in the evolution pattern of his Q-wave anteroseptal myocardial infarction medslides.com

  25. Case Study 1 The most appropriate therapy for this patient is: • Salicylates • Indomethacin • Corticosteroids • Colchicine medslides.com

  26. Case Study 2 A 36-year old woman presents to the ER for the second time in a week with pleuritic chest and left shoulder discomfort and a low-grade fever. She had been in an argument with her boy friend 6 days earlier during which he grabbed her by both shoulders and shook her violently. medslides.com

  27. Case Study 2 HR 82, BP 94/70.Left iris is green, right is blueShe is slender, has a straight back, long fingers, high-arched palate, and slight pectus excavatum.A pericardial friction rub is present. medslides.com

  28. Case Study 2 A chest radiograph shows an increased cardiac silhouette and a small left pleural effusion.ECG shows NSR with diffuse J-point elevation and PR-segment depression in lead 2. medslides.com

  29. Case Study 2 Which one of the following tests should you order? • An erythrocyte sedimentation rate • A creatine kinase determination • An echocardiogram • An antinuclear antibody • A D-dimer medslides.com

  30. Constrictive Pericarditis • rarely develop after an episode of acute idiopathic pericarditis • more likely to develop after subacute pericarditis with effusion that evolve over several weeks • more frequent after purulent bacterial or tuberculous pericarditis medslides.com

  31. Constrictive Pericarditisin the United States • Idiopathic • radiotherapy • cardiac surgery • connective tissue disorders • dialysis • bacterial infection medslides.com

  32. CONSTRICTIVE PERICARDITIS medslides.com

  33. Tuberculous Pericarditis • Incidence of pericarditis in patients with pulmonary TB ranged from 1-8% • Physical findings: fever, pericardial friction rub, hepatomegaly • TB skin test usually positive • Fluid smear for TB often negative • Pericardial biopsy more definitive medslides.com

  34. Constrictive Pericarditis Physical Findings • Jugular veins • prominent X and Y descent •  with inspiration (Kussmaul’s sign) • Lungs - possible pleural effusion • Heart - diastolic pericardial knock • Abdomen: ascites, pulsatile liver • Extremities: peripheral edema medslides.com

  35. Constrictive PericarditisDiagnosis • often not recognized in its early phases by exam, x-ray, ECG, echo • tendency to overlook elevated JVP subacute chronic diastolic knock + ++ Kussmaul’s + ++ paradoxical pulse ++ ++ medslides.com

  36. Constrictive Pericarditiscatheterization findings • Right and left heart pressure are measured simultaneously • right and left ventricular diastolic pressure are elevated and nearly equal; may show classic “square root sign” • RA pressure has steep X and Y descents and may rise during inspiration (Kussmaul’s sign) medslides.com

  37. Case Study 3 A 42-year old man presented because of increasing abdominal girth and lower extremity edema. A decade ago he underwent treatment for Hodgkin’s disease that included mantle field radiation therapy and MOPP chemotherapy. medslides.com

  38. Case Study 3 HR 84, BP 100/70 JVD not observed at 45 degrees Absent vocal fremitus at right base Heart sound is distant An early-mid diastolic sound 3+ pitting edema bilaterally medslides.com

  39. Case Study 3 What is the most likely diagnosis? • Effusive pericarditis • Occult constrictive pericarditis • Constrictive pericarditis • Idiopathic dilated cardiomyopathy • Restrictive cardiomyopathy medslides.com

  40. Types of Effusive Fluid • serous • transudative - heart failure • suppurative • pyogenic infection with cellular debris and large number of leukocytes • hemorrhagic • occurs with any type of pericarditis • especially with infections and malignancies • serosanguinous medslides.com

  41. Dignostic Evaluation • Chest x-ray • usually requires > 200 ml of fluid • cannot distinguish between pericardial effusion and cardiomegly • Echocardiography • standard for diagnosing pericardial effusion • convenient, highly reliable, cost effective • false positives (M-mode)- left pleural effusion, epicardial fat, tumor tissue, pericardial cysts medslides.com

  42. Noncompressing Effusion • asymptomatic unless they are large enough to compress adjacent organs • dysphagia • cough • dyspnea • hoarseness • hiccups • abdminal fullness • nausea medslides.com

  43. ECG in Pericardial Effusion • Diffuse low voltage • amount of fluid • electrical conductivity of the fluid • Electrical alternans • alternating amplitude of the QRS • produced by heart swinging motion • also seen in PSVT, HTN, ischemia medslides.com

  44. Cardiac Tamponade • Decompensated cardiac compression from increased intracardaic press medslides.com

  45. Cardiac Tamponade • Early stage • mild to moderate elevation of central venous pressure • Advanced stage •  intrapericardial pressure ventricular filling,  stroke volume • hypotension • impaired organ perfusion medslides.com

  46. Beck’s Triad • Described in 1935 by thoracic surgeon Claude S. Beck • 3 features of acute tamponade • Decline in systemic arterial pressure • Elevation in systemic venous pressure (e.g. distended neck vein) • A small, quiet heart medslides.com

  47. Cardiac TamponadeBedside Diagnosis • Elevated jugular venous pressure • Paradoxical pulse medslides.com

  48. Pulsus Paradoxus • an exaggerated drop in blood pressure with inspiration (>10mmHg) • tamponade without pulsus • atrial septal defect • aortic insufficiency • LVH with  LVEDP • pulsus without tamponade • COPD, RV infarct, pulmonary embolism medslides.com

  49. Echocardiography • Pericardial effusion • highly reliable • Cardiac tamponade • RA and RV diastolic collapse • reduced chamber size • distension of the inferior vena cava • exaggerated respiratory variation of the mitral and tricuspid valve flow velocities medslides.com

  50. Pericardiocentesis • Diagnostic tap • usually not indicated • rarely have positive cytology or infection that can be diagnosed • Therapeutic drainage • indicated for significant elevation of the central venous pressure medslides.com

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