Pericarditi

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

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.
B. Bacterial infection Tubercle bacilli
Staphylo coccus
Strepto coccus
Pneumo coccus

C.Fugal Infection
D.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.

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 ).

 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 .

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 .
v. Myxedema.
vi.Malignancy like lymphoma.
vii.Aortic dissection + myocardial
infection.

viii.Cobalt pear cardiomyopathy. Pear

Myocarditis
cardiomyopathy

can. Lead to
ix. Radiation therpay .

Clinical Finding
Depond on the:
- Type of inflammation.
- Sevirety of inflammation.
- Formation of pericardial fluid.
1. Dry pericarditis.
2. Percardial effusion without cardiac
temponade.
3. Cardiac temponade.
4. Pericardial constriction.

ECG:

1/ Dry Pericarditis or
Fibronous:
Symptoms

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.

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.

Lab Finding:
1. CBC leu kocytosis 20.000.
increase sedmentation rate.
Increase CRP

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

ECHO:

2/ Precardial effusion without temponade:

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

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.

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

ECHO:
It is 99% diagnostic to pericardial

effusion.
ECHO: Showed free area between
pericardium and posterior wall of L.
ventricle.

 The ECHO not useful in early stage of

dry pericarditis but in late when
there is fibrosis.

Differential Diagnosis
Heart failure:
3rd heart sound. Normal
heart
sound.
In
the
pericardial effusion there is
distant heart sounds and
apical impulse not visible.

Complication of pericardial
effusion:

Cardiac temponade
2. Fibrosis:
1.

minimal effusion and this called

sero constrictive or sub acute
inflammation.

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.

Treatment of pericardial
effusion:
1.Pericardio- synthesis:
This is diagnostic and
therapeutic.

2. Thoracotomy:
( an open drainage).

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.

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

Signs:
- Increase venous pressure :
(Kussmauls sign). called inspiratory
filling of superior vena cava.

- Cardiac impulse:
Are not palpable.

- Heart sound:

Are distant and this is same as P. effusion.

ECG:
- Low voltage and T wave change.
- Non specific change.

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

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.

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.

ECG:

Treatment:
1. pericardio

syntheasis:

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.

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

 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.

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).

- 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).

Rigt hypocondrial pain:

 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:

ECG:
Non specific.

X-Ray:
Intraprecardial cacification

ECHO:
Absent of late diastolic filling.

D.D
Superior venacaval

ospstruction.
Restrective cardiomyopathy.
Endomyocardial fibrosis.

Treatment:
Pericardiutomy