pericardial diseases Year 4 Internal Medicine Notes

pericardial diseases Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.2 / Ngugi -- Slide 1 Acute pericarditis Slide 2 INTRODUCTION The pericardium is a double-layered sac;\nHas visceral pericardium and the fibrous parietal pericardium separated by a small quantity (15–50 mL) of fluid, an ultrafiltrate of plasma.\nFunctions; By exerting a restraining force it prevents sudden dilation of the cardiac chambers, especially the right atrium and ventricle, during exercise and with hypervolemia. It also restricts the anatomic position of the heart, and probably retards the spread of infections from the lungs and pleural cavities to the heart. However,total absence of the pericardium, either congenital or after surgery, does not produce obvious clinical disease.\nIn partial left pericardial defects, the main pulmonary artery and left atrium may bulge through the defect; very rarely, herniation and subsequent strangulation of the left atrium may cause sudden death. Slide 3 Intro ct’ Pericarditis can be classified into 3; I. Acute pericarditis (<6 weeks)\nA. Fibrinous\nB. Effusive (serous or sanguineous)\nII. Subacute pericarditis (6 weeks to 6 months)\nA. Effusive-constrictive\nB. Constrictive\nIII. Chronic pericarditis ( 6 months)\nA. Constrictive\nB. Adhesive (non constrictive) Slide 4 Etiology Idiopathic Infections\nNeoplasms Cardiac causes Autoimmunity Drugs Metabolic causes Trauma\nRadiation Slide 5 infections A. Viral (coxsackievirus A and B, echovirus, herpesviruses, mumps, adenovirus, hepatitis, HIV, EBV, CMV)\nB. bacterial (Tuberculosis, pneumococcus, Streptococcus, Staphylococcus, Neisseria, Legionella, Chlamydia, Lyme disease)\nC. Mycoplasma\nD. Fungal (histoplasmosis, coccidioidomycosis, Candida, blastomycosis E. parasitic – Echinococcus, amebiasis, toxoplasmosis F. Infective endocarditis with a ring valve abscess Slide 6 neoplasms Metastatic Lung or breast cancer, Hodgkins disease, leukemia, melanoma Primary Rhabdomyosarcoma, teratoma, fibroma, lipoma, leiomyoma, angioma\nparaneoplastic Slide 7 Cardiac causes Early infarction pericarditis Late postcardiac injury symptom(Dressler's syndrome) Myocarditis Dissecting aortic aneurysm Slide 8 Autoimmune causes Rheumatic disease Lupus, rheumatoid arthritis, vasculitis, scleroderma, mixed connective disease Other\nGranulomatosis with polyangiitis(Wegener’s), polyarteritis nodosa, sarcoidosis, IBD, rheumatic fever Slide 9 Metabolic causes Uremia Hypothyroidism Ovarian hyper stimulation syndrome Slide 10 trauma Iatrogenic Blunt or penetrating Slide 11 trauma Iatrogenic Blunt or penetrating Slide 12 Acute pericarditis Refers to the inflammation of the pericardial sac It is the most common disorder involving the pericardium Slide 13 Clinical presentation Chest pain Sudden in onset Usually retrosternal or substernal Pleuritic and sharp in nature Exacerbated by coughing and inspiration Worsens when in supine position and improves upon sitting upright or leaning forward Often radiates to the neck, left shoulder or the trapezius muscle Slide 14 Pericardial friction rub Present in 85% of cases A high pitched scratchy or squeaky sound best heard with the diaphragm at the LSB with the patient leaning forward Has three components which correspond to atrial systole, ventricular systole, early diastole Slide 15 diagnosis Diagnostic criteria Classic type of chest pain Pericardial friction rub Typical ECG changes New or worsening pleural effusion Slide 16 ECG changes findings Stage one (1st hours to days); characterized by diffuse ST elevation (concave in configuration) Stage 2(1st week) characterized by normalization of ST and PR segments Stage three; diffuse T wave inversions Stage four; Normalization of the ECG or indefinite persistence of T wave inversions Slide 17 Pleural effusion Echo cardiogram CT scan MRI Slide 18 treatment Should be targeted to the underlying etiology Inflammation NSAIDs\nibuprofen, naproxen, indomethacin, aspirin Should be given long with a Ppi Steroids -prednisone, methoprednisolone\nSteroids have shown incidence of high recurrence thus should be given as second line or when NSAIDs are contraindicated,\nSteroids are contraindicated in uremic pericarditis patients or autoimmune pericarditis conditions Slide 19 To reduce incidence of recurrence Colchine as an add on to NSAIDs Contraindications same as NSAIDs, in PUD and end stage renal disease Slide 20 Treat the causative agent Uremic patients- dialysis Neoplasia- chemo or radiation Autoimmune- immunosuppressants Slide 21 Criteria for hospitalization Fever 38 degrees Celsius and leukocytosis Evidence suggesting cardiac tamponade A large pericardial effusion 20mm Immunosuppressed patients History of oral anticoagulant therapy Acute trauma\nFailure to respond within seven days to NSAID therapy Elevated cardiac troponin suggesting myopericarditis Slide 22 Cardiac tamponade Slide 23 Introduction Pericardial effusion is the presence of an abnormal amount of fluid(15-50 ml) and or an