Pericarditis

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

Causes: 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 after 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 can.

Lead to ix. Radiation therpay .
Myocarditis cardiomyopathy

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:
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 it s 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:

1.

Cardiac temponade 2. Fibrosis:

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 :
(Kussmaul s 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: 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.

Symptoms:
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