Pericardial disease

1. acute

2. subacute

3. chronic

-acute <6 weeks

-fibrinous

-effusive with fluid that is either serous or sanguineous (has blood in it)

- 6 weeks to 6 months

-effusive-constrictive

-constrictive

> 6 months

-constrictive

-effusive

-adhesive (nonconstrictive)- adhering to the heart

-pyogenic (bacteria producing purulent material) (pneumoccoccus, stretococcus, staphylococcus, neisseria, legionella

-TB

- syphilitic

-protozoal/parasitic

Rheumatic fever,

Collagen vascular disease (SLE, RA, ankylosing spondylitis, scleroderma, ARF, wegener's granulomatosis)

drugs

post cardiac injury such as post MI, postpericardotomy, posttramatic

-chest pain usally in acute pericarditis

-servere, retrosternal and left precordial

-radiates to back and left trap ridge

often is pleuritic

-sometimes it is constant and radiates into either or both arms

-pain is worse in supine position, better when sitting up and leaning forward

-pericarditis is pleuritic. Pt will have increased pain with breathing

-friction rub

1. pericardial friction rub

2. paradoxical pulse

high-pitches, scratching, grating sound-heard in pre-systolic, systolic and early diastolic

best heard when pt sitting, leaning forward, during inspiration or expiration

use diaphragm part of stethoscope and listen at the left lower sternal border

greater than normal (10 mmHg) inspiratory drop in sytsolic arterial pressure.

this also occurs in 1/3 of pts with constrictive pericarditis, right ventricular infarction, hypovalemia, COPD, pulmonary embolus

-widespread elevation of ST segments due to subepicardial inflammation

-elevation will be seen in every single lead across the EKG

-elevated cardiac enzymes (less than one would expect with the widespread ST segment elevation)

-echo may revela pericardial effusion. If it develops quickly this may cause tamponade. May decreaes heart sounds and prevent detection of friction rub.

-pleuritic CP

-pericardial friction rub

-paradoxical pulse

-widespread elevation of ST segments

-enlarged cardiac silhouete

-echo is the main diagnostic tool

-pericardiocentesis-fluid is removed. This is both a tx and diagnostic tool.

-CT or MRI can confrim and define pericardial thickening

-want to observe for development of effusion

-pericardiocentesis immediately. A tamponade is LIFE THREATENING!

-remove as much fluid as possible

-surgical drainage may be required with limited thoracotomy

1. viral or idiopathic

2. low grade fever

3. mild constitutional sxs

4. precordial friction rub is usually present

5. usually last few days to 4 weeks (tamponade is rare, ST segment changes fone in 1 or more weeks, abnormal T waves may persist for several years)

6. no specific therapy (bedrest and ASA; if ASA is ineffective give prednisone and taper off), avoid anticoagulatants, colchicine may prevent recurrent cases

  -this occurs after cardiac surgery, cardiac trama, catheter perforation of the heart, after AMI (Dressler's syndrome)

-mimics the "typical case of acute pericarditis"

-responsible mechanism is unknow

-often no txt other than analgesia and ASA

-usually lasts 4 weeks

-TB

-myxedema

-neoplasms, SLE, RA, mycotic infections, radiation therapy, severe chronic anemia, pyogenic infections, chylopericardium

pericardiocentesis

pericardectomy may be required

-healing of acute fibrinous pericarditis or chronic pericardia effusion=fromation of granulation material

-granulation material contracts and forms a firm scar.

-scar interferes w/filling of ventricles

-can also follow trauma, cardiac operation, mediastinal irradiation, neoplasms, RA, SLE, CRF with uremia

-underlying abnormality with the inability of the ventricles to fill

-ventricular end diastolic and SV are reduced

-end diastolic pressures are elevated

-fibrotic process can exten to the myocardium

-appear chronically ill

-weakness, fatigue

-increased abd girth, edema

-exertional dyspnea common, distended neck veins (positive Kussmaul's sign-no systolic pressure drop during inspiration)

-paradoxical pulse is present in 1/3 of cases

-hepatomegaly

-ascites is common

-low voltage ECG

-afib in 1/3rd of cases

echo is test of choice

MRI or CT requried to confirm pericardial thickening

1. Cor pulmonale (negative Kussmaul’s sign)

2. Tricuspid stenosis ( characteristic murmur and mitral stenosis are usu (ally present)

3. Restrictive cardiomyopathy ( CT and MRI reveals ventricular wall hypertrophy, important differentiation = constrictive pericarditis is curable) Restrictive is not!!

1. pericardial resection (5-15% mortality rate)

2. risk of surgery increased with calcific penetration of myocardium, serverity of myocardial atrophy, extent of hepatic or renal impairment or general condition of pt.

round or lobulated

most commonly ar right costophrenic angle

asymptomatic

confused with tumors

-most are secondary to malignant neoplasms (carcinoma of bronchus, breast, lymphoma or melanoma)

-most common primary malignancy is mesothelima

-surgery is needed to make dx and define tx-usually palliative

-sig mortality rate