CVS

Pericardial diseases

Anatomy of the pericardiumConsists of parietal and visceral membranes.The space between them(pericardial space is normally filled by a lymph like fluid.The fluid’s normal quantity is 15-50 ml.This lubricates the surface of the heart.

Functions of the pericardium

Prevents sudden dilatation of the cardiac chambers.Facilitates atrial filling.Fixes the heart in it’s position.Retards the spread of infection from surrounding structures.

Acute pericarditis

Etiological classification Infectious pericarditis. Non-infectious pericarditis Pericarditis related to autoimmune diseases

Infectious pericarditis

Viral – coxaci B, mumps, echovirus,HIVPyogenic – Pnumococcal,Stphylococcal, Neisseria, TuberculousFungal – Histoplasma, Coccidomycosis, CandidaOthers - Syphilitic, protozoal, parasitic

Non –infectious pericarditis Acute myocardial infarction Chronic renal failure Neoplasm (Primary and secondary) Hypothyroidism Trauma Post-irradiation Familial Mediterranean fever Idiopathic

Pericarditis due to hypersensitivity 

1. Rheumatic fever2. Collagen vascular diseases SLE, RA, PAN3. Drugs procainamide, hydralazine, INH4. Post cardiac injuryPost myocardial infarction (Dressler’s syndrome)Post traumaPost surgery

Clinical Manifestations

Fever Generalized prostration Pain: Stabbing Sever Retrosternal and left precordial Radiates to left shoulder and back Aggravated by breathing coughing and change in posture. Improves by leaning forward and increased by lying flat



4. Pericardial friction rub: High pitched superficial leathery sound. Usually systolic, might be heard also in diastole, sometimes have three components per cardiac cycle. Best heard if the diaphragm is applied firmly on the left lower sternal border Variable in intensity and may be intermittent. Its absence doesn't exclude the Dx.

Electrocardiography

Widespread elevation of the ST segment. The ST segment have an upward concavity. There is no significant Q wave changes. After few days the ST segment retunes to normal. After the ST segment returns to normal the T wave becomes inverted.

ECG Changes Myocardial Infarction Acute Pericarditis

ST elevation , convex upwardUsually localizedMay be reciprocal changesST elevation , Q wave – T wave inversion may be together ST elevation , concave upwardUsually diffusedNo reciprocal changesStart ST elevation – back normal – T wave inversionNo pathological Q waveMay be PR segment depression

ST ELEV

Treatment
Bed rest Specific treatment if the causative agent is recognized as in TB. Non-steroidal anti-inflammatory drugs: Aspirin 900 mg. qid Indomethacine 25-75 mg. qid Steroids - Prednisolon 40-60 mg.\day

Pericardial effusionAnd cardiac temponade

Fluid may accumulate in the pericardial space after any type of pericarditis. If it reaches a degree that impedes the normal inflow of blood into the ventricles, it is called Cardiac temponade. Cardiac temponade is fatal if not recognized and treated promptly.



Causes
Neoplastic diseases Idiopathic pericarditis Chronic renal failure Bleeding Surgery Trauma Anticoagulant

Clinical features

Severity depends not only on the amount of the accumulated fluid, but also on the rapidity of accumulation. So the amount of fluid necessary to produce temponad may be as little as 200cc, to as much as 2 liters

Clinical features

Dyspnea Weakness Palpitation Rapid thready pulse Pulsus paradoxus JVP is elevated Cardiac apical impulse is not palpable Quiet heart sounds

Electrocardiography

May be normal Usually low voltage May show evidence of pericarditis Some times QRS voltage my vary from beat to beat (QRS alternance)

Chest X - Ray

Enlarged cardiac silhouette Flask shape heart

Echocardiography

Definitive diagnosis Fluids in the pericardial space Ventricular filling is impeded

Treatment

Every patient with evidence of pericarditis should be admitted to detect this grave complication. If there is only evidence of effusion, then continue treatment as pericarditis. If there is evidence of temponade, then Pericardiocentesis should be done immediately.

Chronic constrictive pericarditis

It results when the healing of an acute fibrinous or serofibrinous pericarditis is followed by obliteration of the pericardial cavity with granulation tissue firm scar encasing the heart calcification.

Causes

It can follow any type of pericardial injury. Usual causes are: TB pericarditis Heamopericardium Viral pericarditis Purulent pericarditis Idiopathic

Clinical features

Symptoms and signs of systemic venous congestion are the hallmark of constrictive pericarditis

Clinical features

FatigueRapid, small volume pulse, st. irregularPulsus paradoxusElevated JVPKaussmal’s signLoud early 3rd. Heart sound Hepatomegaly Ascitis Peripheral edema Weight loss Minimum dyspnea No Orthopnea

Electrocardiography

Non specific Low voltage Sometimes atrial fibrillation

Chest X – raySmall cardiac silhouettepericardial calcification

Echocardiography
Diagnostic

C-T scan and MRI

Treatment
Conservative Bed rest Salt restriction Diuretics Anti Tb Surgery Dramatic improvement Carries a high mortality