Chronic accumulation is accommodated by the expanding pericardium
Final result ：
The exudate was completely dissolved and absorbed
Organization -> calcification of pericardium -> constrictive pericarditis
Acute pericardial effusion
The pressure of the pericardial cavity ↑
FV( filling volume) of the ventricular diastole ↓
SV( stroke-volume) ↓
Clinical Manifestations --- fibrous protein pericarditis
Chest pain (Symptoms)
retrosternal or precordium, midsection
sharp pain, dull pain, compression
deep breathing, cough, and lying down.
sitting and leaning forward.
Pericardial friction rub
Both systole and diastole
This finding is diagnostic
Clinical Manifestations --- Pericardial effusion
Pressure symptoms ：
dysphagia （ esophagus)
physical sign of the heart
tachycardia, indistinct heart sounds
Ewart sign (consolidation of lower lobe of left lung)
SBP↓ ， pulse pressure↓
even paradoxical pulse .(there is an exaggerated reduction of the pulse >10mmHg during inspiration)
Congestion of systemic circulation
distended jugular vein
Clinical Manifestations --- Cardiac tamponade
Acute ： Beck’s trilogy
Hypotension or shock
Distended jugular vein
Indistinct heart sounds
Subacute or chronic ：
venous pressure↑ ↑
congestion of systemic circulation
Kussmaul sign( dilation of jugular vein during inspiration)
Laboratory findings --- ECG
Stage I: ST segment elevation (concave upward not convex) in all leads except avR and V1 without reciprocal ST segment depression (which occurs in MI) (Several hours later).
Stage II : ST segments return to baseline, the initially upright T waves flatten (several days later)
Stage III: T waves invert (weeks later)
Stage IV: T waves revert to normal (weeks or months later))
Other changes: Large effusion can cause both reduced voltage and electrical alternans.
EKG of Acute pericarditis (Stage I)
Acute inferior myocardial infarction
Laboratory findings --- Chest x-ray film
Cardiac shadow has an enlarged “water-bottle” appearance.
Clear lung field.
Cardiac shadow changes with postures.
Laboratory findings ---Echocardiography
This is the best noninvasive investigation for confirming diagnosis of a pericardial effusion
Laboratory findings --- Pericardiocentesis
1.Pericardiocentesis can help to make diagnosis .
Fluid should be sent for culture and assay
Protein, glucose and LDH assays : LDH, glucose and protein determine if fluid is a transudate or exudate;
Cytology and tumor marker : CEA, AFP, CA125 and so on;
ANA assay : if collagen vascular disease is suspected.
2. Pericardiocentesis can relieve the pressure of pericardial cavity.
Diagnosis of Acute Pericarditis
Chest pain aggravated by coughing, inspiration,or recumbency
Pericardial friction rub on auscultation
Charateristic EKG changes
Chest X-ray and UCG may find pericardial effusion
Differential Diagnosis of Acute Pericarditis often seldom often seldom Often severely Chest pain seldom seldom often often obviously ， occur early Pericardial friction rub often seldom High fever seldom Constant fever Fever History of cardiac injury such as operation, myocardial infarction, may often recurrent Frequently caused by metastatic tumour Accompanied with original infection lesion or septemia Accompanied with primary TB History of up respiratory tract infection ， acute onset ， often recurrent Histrory Postpericardiostomy syndrome Maligancy Purulent pericarditis Tuberculous pericarditis Acute idiopathic pericarditis
Differential Diagnosis of Acute Pericarditis Often serosity Often hematic Purulent Often hematic Grass yellow or hematic Characteristic Medium Large Large Large Little Volume of pericardial effusion — — + — — Blood culture Normal or slightly increase Normal or slightly increase Significantly increase Normal or slightly increase Normal or increase Leukocyte count Postpericardiostomy syndrome Maligancy Purulent pericarditis Tuberculous pericarditis Acute idiopathic pericarditis
Differential Diagnosis of Acute Pericarditis Steroid Treat original diseases, Perecardiocentesis Antibiotic or pericardiotomy Anti-tubercle bacillus NSAIDs Treatment None None Purulent bacteria Tubercle bacillus may be found None Bacteria More lymphocyte More lymphocyte More neutrophil More lymphocyte More lymphocyte Classification of leukocyte Postpericardiostomy syndrome Maligancy Purulent pericarditis Tuberculous pericarditis Acute idiopathic pericarditis
Collagen vascular disease
2. Relieving pain and inflammation:
NSAIDs and steroids
3.If symptoms are severe, pericardiocentesis is indicated to remove fluid.
Constrictive pericarditis is a thickening and fibrosis of the pericardium that occurs long after an acute episode of pericarditis. It produces decreased diastolic filling .
TB is a leading cause in underdeveloped countries including China, about 40%.
Others: Purulent inflammation, Pericardial injury, Radiation therapy etc.
Dyspnea on exertion and orthopnea
Distended jugular vein
Heart sounds are distant and a pericardial knock is detected after S 2
SBP↓ 、 DBP↑ 、 pulse pressure↓
Low voltage in limb leads
T wave is low or upside down
Pericardial thickening in most cases can be demonstrated
Diagnosis of Constrictive pericarditis
1.Congestion of systemic circulation: distended
jugular vein, edema
2.Pericardial knock on auscultation
3.X-ray,Magnetic resonance, computed
tomography, or echocardiographic imaging
showing a thickened or calcified pericardium
1.Pericardiectomy as early as possible.
2.Antituberculous therapy may be required if the underlying cause is tuberculosis and should be continued for 1 year.
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