Pericarditis

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Pericarditis
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Definition
Is inflammation of pericardial layer of the
heart. pericardial layer covers the heart and
protect it from any infection.
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Causes

• I. Infection is the most important cause

• A. Viral infection this is the most important
  cause in infection coxachi A virus.
• And B commonest one. B3 , B5.
• ECHO virus, influenza V. hepatitis V.
• Bacterial infection Tubercle bacilli
• Staphylo coccus
• Strepto coccus
• Pneumo coccus

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1. Fugal Infection
2. Parasitic Infection

Those causes same as the causes of myocordotis
and so the patient with acute myocarditis can
present with pericarditis and vice versa that the
disease could start in the myocardium and spread
to the pericardium.
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II. Hyper sensitively reaction.

• Follow myocardial infarction dressler syndrome
  ).post pericardits 2nd ry to M.I in 3rd or 4th
  day of infection.(late presentation ).

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• Post pericardiotomy syndrome .auto immune self
  limiting disease affect pleura and pericardium
  .common af ter cardiac surgery specially mitral
  valve mitral comissuratomy
• Serum sickness and drug reaction as (hydralazine)
  
• III. Direct and indirect wound as stab wound .
  

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• Iv.Metabolic disorders as uraemia. (most
  important). Present with pericaditis effusion and
  espically after introduction of renal dialysis
  .The pericardial effusion enhanced after renal
  dialysis .
• Myxedema.
• Malignancy like lymphoma.
• Aortic dissection myocardial infection.

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• Cobalt pear cardiomyopathy. Pear can. Lead to
  
• Radiation therpay .

Myocarditis cardiomyopathy
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Clinical Finding

• Depond on the
• - Type of inflammation.
• - Sevirety of inflammation.
• - Formation of pericardial fluid.
• Dry pericarditis.
• Percardial effusion without cardiac temponade.
• Cardiac temponade.
• Pericardial constriction.

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ECG
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1/ Dry Pericarditis or Fibronous
Symptoms

• Chest pain
• It is precardial, sever, radiate to shoulder,
  so mimic the acute myocardial infraction pain.
  But the pain of pericarditis increase intensity
  with inspiration or lying flat and improve when
  standing or sit down or leaning forward ( (???
  ??????.
• Fever
• Arthralgia rigors, anxiaty and general
  weakness.

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Signs

• Pericardial rub Is the harsh sound continuous
  atrail systole, Ventricular systole and
  ventricular diastole. It is superficial sound has
  no relation to heart sound. Nearly periodical
  area. and easy to heard when the patient hold
  its breathing so you should differentiate
  between pleural rub and pericardial rub. Pleural
  rub might be heard during inspiration.
  Pericardial rub start to disappear when effusion
  develops. And pericardial pain improve.

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Lab Finding

• CBC leu kocytosis 20.000.
• increase sedmentation rate.
• Increase CRP

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X-Ray

• Normal chest X-Ray.
• No signs of cardiac enlargement.
• No signs of pulmonary congestion.

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ECHO
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Symptoms
2/ Precardial effusion without temponade

• disapperance of cheast pain.
• 1. ECG changes - Flat T wave.
• - Low voltage ECG

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Signs

• Blood pressure normal.
• Pulse normal.
• Only heart sound become distant.
• Invisible cardiac pulse.
• Pericardial rub might disappear or it may remain
  and this indication to previous pericarditis so
  no pain and no rub.

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ECG

• Change in T wave not specific for P. effusion.
• T wave flat or T wave inverted.
• Low voltage.
• Low QRS complex.

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ECHO

• It is 99 diagnostic to pericardial effusion.
• ECHO Showed free area between pericardium and
  posterior wall of L. ventricle.

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• The ECHO not useful in early stage of dry
  pericarditis but in late when there is fibrosis.

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Differential Diagnosis
Heart failure

• 3rd heart sound. Normal heart sound. In the
  pericardial effusion there is distant heart
  sounds and apical impulse not visible.

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Complication of pericardial effusion

• Cardiac temponade
• 2. Fibrosis
• minimal effusion and this called sero
  constrictive or sub acute inflammation.

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Treatment of pericarditis without effusion

1. Salicylate NSID in high dose.
2. Bed Rest.

most patient respond to those points. If
patient after 10 day of starting salicylate or
NSIDrugs if still have signs or symptoms of
pericarditis corticosteroids can be added but
role of corticosteroids is doubt if start from
beginning of the disease.
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Treatment of pericardial effusion

• Pericardio- synthesis
• This is diagnostic and therapeutic.
• 2. Thoracotomy
• ( an open drainage).

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3/ Cardiac Temponade

• In Temponade the amount of fluid inside
  pericardial sac is increased. When intra
  pericardial pressure equal to the diastolic
  pressure in the heart. ( the right vertical or
  right atrial pressure) then temponade develops.
• The right side of the heart has less diastolic
  pressure than left side of the heart and for that
  reason the cardiac temponade compress right side
  of the heart because the pressure reach to
  diastolic pressure of right ventricle or right
  atrium before reach to left ventricle and so all
  patients present with right side heart failure
  heart problem.

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Symptoms

• Patients is unconscious, severly sweating,
  dizzness or may reach a circulatory shock.

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Signs

• Increase venous pressure
• Cardiac impulse
• Are not palpable.
• Heart sound
• Are distant and this is same as P.
  effusion.

(Kussmauls sign). called inspiratory filling of
superior vena cava.
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ECG

• Low voltage and T wave change.
• Non specific change.

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ECHO

• Is most helpful diagnotic method for cardiac
  tamponade.
• Fluid inside between pericardium and posterior
  wall of ventride.

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Invasive Method

• Abscent.Y Descend
• C.Tamponede the diastolic pressure in the
  pericardial sac equal to diastolic pressure in Rt
  ventricle and so there is interference with the
  filling of Rt ventricle and so absent of Y
  descent. For that reason it is an acute emergency
  we would remove fluid to give chance to Rt
  ventricle to dilate.

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Differentia Dignosis

• From severly P. Emblism or acute myocardial
  infraction or any acute emergency state.
• Type of pain is similar
• But pain of pericardial when lying flat.

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ECG
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Treatment

• 1. pericardio syntheasis

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4. Constrictive Pericardits

• There is sero constrictive and constrictive
  pericarditis. The difference between them, that
  the sero contrictive affect Rt pericardium
  minimal fluid in pericardiuml so we called it
  sero constrictive or sub acute type.
• In constrictive pericarditits, whole
  pericardium is thickened and fibrosis so make
  thick fibrous layer around heart.

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Symptoms

• Is swelling of abdomen and lower limb as it
  mimic presentation as acute Rt heart failure.

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• Dyspnea is minmal in constrictive pericarditis is
  not presenting symptom but it can occur.
• Anaroxia.
• General weakness wasting.
• In constrictive pericarditis, the history of
  previous attack of pericarditis is important.

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Signs

• Low blood pressure.
• Pulsus paradoxus
• Is present in constrictive pericarditis and
  cardiac tamponade and abscent in pericardial
  effusion without tamponade and in dry
  pericarditis.
• (it is change in sytolic blood pressure more than
  10 mm of Hg during insiration).

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• Arrythmia
• (Atrail Fibrillation) in 30 in constrictive
  pericarditis ( one of causes of artail
  fibrillation is constrictive pericarditis) high
  jaqular venous pressure.
• No deep Y wave descent
• This opposite to constrictive pericarditis
  when there is Y wave (deep descent).

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• Rigt hypocondrial pain

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• But in constrictive dilated Rt ventricle at early
  diastolic rapidy and there is Y rapid descent
  until the pressure inside Rt ventricle equal to
  whole distolic pressure in the pericardium so
  there is squair root phenomena.
• Percardial knock
• Ascitis

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ECG

• Non specific.

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X-Ray

• Intraprecardial cacification

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ECHO

• Absent of late diastolic filling.

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D.D

• Superior venacaval ospstruction.
• Restrective cardiomyopathy.
• Endomyocardial fibrosis.

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Treatment

• Pericardiutomy