17 pericardial disease


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  • Avoid too much or too less blood inflow into the heart, modulate the pressure of the ventricle
  • Any treatable underlying cause should be saught and treated, however, most causes of pericarditis are viral and idiopathic. The main aims of management are therefore relief of chest pain and bed rest.
  • 17 pericardial disease

    1. 1. Pericardial Disease Wutao Zeng Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University
    2. 2. General characteristics ( Normal Pericardial Anatomy and Physiology ) <ul><li>1.Pericardium is the membranous sac surrounding the heart. </li></ul><ul><li>2. The pericardium consists of two layers: visceral layer and parietal layer. </li></ul><ul><li>3.There is about 50ml pericardial fluid in the pericardial cavity. </li></ul>
    3. 3. The normal functions of the pericardium <ul><li>Maintaining an optimal cardiac shape. </li></ul><ul><li>Reducing friction between the beating heart and adjacent structures. </li></ul><ul><li>Protecting the heart from other diseases which are caused by the neighboring organs: inflammation , TB, cancer etc. </li></ul><ul><li>Preventing the overfilling of the heart. </li></ul>
    4. 4. Classification of Pericardial Diseases <ul><li>Congenital defect </li></ul><ul><li>Pericarditis </li></ul><ul><ul><li>acute pericarditis </li></ul></ul><ul><ul><li>pericardial effusion </li></ul></ul><ul><ul><li>constrictive pericaditis . </li></ul></ul><ul><li>Pericardial neoplasm </li></ul><ul><li>Pericardial cysts </li></ul>
    5. 5. Acute pericarditis
    6. 6. Definition <ul><li>Acute pericarditis is an inflammation </li></ul><ul><li>of the pericardium. </li></ul>
    7. 7. Etiology <ul><li>The disease may be idiopathic or secondary to other diseases, for example </li></ul><ul><ul><li>Viral infection: coxsackievirus B, CMV </li></ul></ul><ul><ul><li>Bacterial infection: Staphylococcus sp, Streptococcus sp, tubercle bacillus </li></ul></ul><ul><ul><li>Post-MI complications </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Collagen vascular disease </li></ul></ul>
    8. 8. Pathology <ul><li>Early stage : </li></ul><ul><ul><li>fibrous protein pericarditis </li></ul></ul><ul><li>Progressive stage : </li></ul><ul><ul><li>Rapid effusive pericarditis -> acute cardiac tamponade </li></ul></ul><ul><ul><li>Chronic accumulation is accommodated by the expanding pericardium </li></ul></ul><ul><ul><li>myopericarditis </li></ul></ul><ul><li>Final result : </li></ul><ul><ul><li>The exudate was completely dissolved and absorbed </li></ul></ul><ul><ul><li>Organization -> calcification of pericardium -> constrictive pericarditis </li></ul></ul>
    9. 9. pathophysiology <ul><li>Acute pericardial effusion </li></ul><ul><li>↓ </li></ul><ul><li>The pressure of the pericardial cavity ↑ </li></ul><ul><li>↓ </li></ul><ul><li>FV( filling volume) of the ventricular diastole ↓ </li></ul><ul><li>↓ </li></ul><ul><li>SV( stroke-volume) ↓ </li></ul><ul><li>↓ </li></ul><ul><li>BP ↓ </li></ul>
    10. 10. Clinical Manifestations --- fibrous protein pericarditis <ul><li>Chest pain (Symptoms) </li></ul><ul><ul><li>Position : </li></ul></ul><ul><ul><ul><li>retrosternal or precordium, midsection </li></ul></ul></ul><ul><ul><li>Character : </li></ul></ul><ul><ul><ul><li>sharp pain, dull pain, compression </li></ul></ul></ul><ul><ul><li>Worsen </li></ul></ul><ul><ul><ul><li>deep breathing, cough, and lying down. </li></ul></ul></ul><ul><ul><li>Relieved </li></ul></ul><ul><ul><ul><li>sitting and leaning forward. </li></ul></ul></ul><ul><li>Pericardial friction rub </li></ul><ul><li>(Signs) </li></ul><ul><ul><li>Both systole and diastole </li></ul></ul><ul><ul><li>This finding is diagnostic </li></ul></ul>
    11. 11. Clinical Manifestations --- Pericardial effusion <ul><li>Symptoms </li></ul><ul><li>Dispnea </li></ul><ul><li>Pressure symptoms : </li></ul><ul><ul><li>dry cough(bronchus) </li></ul></ul><ul><ul><li>hoarseness(laryngeal nerve) </li></ul></ul><ul><ul><li>dysphagia ( esophagus) </li></ul></ul><ul><li>Signs </li></ul><ul><li>physical sign of the heart </li></ul><ul><ul><li>tachycardia, indistinct heart sounds </li></ul></ul><ul><ul><li>Ewart sign (consolidation of lower lobe of left lung) </li></ul></ul><ul><li>Hypotension </li></ul><ul><ul><li>SBP↓ , pulse pressure↓ </li></ul></ul><ul><ul><li>even paradoxical pulse .(there is an exaggerated reduction of the pulse >10mmHg during inspiration) </li></ul></ul><ul><li>Congestion of systemic circulation </li></ul><ul><ul><li>distended jugular vein </li></ul></ul><ul><ul><li>edema </li></ul></ul>
    12. 12. Clinical Manifestations --- Cardiac tamponade <ul><li>Acute : Beck’s trilogy </li></ul><ul><ul><li>Hypotension or shock </li></ul></ul><ul><ul><li>Distended jugular vein </li></ul></ul><ul><ul><li>Indistinct heart sounds </li></ul></ul><ul><li>Subacute or chronic : </li></ul><ul><ul><li>venous pressure↑ ↑ </li></ul></ul><ul><ul><li>congestion of systemic circulation </li></ul></ul><ul><ul><li>Kussmaul sign( dilation of jugular vein during inspiration) </li></ul></ul>
    13. 13. Laboratory findings --- ECG <ul><li>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). </li></ul><ul><li>Stage II : ST segments return to baseline, the initially upright T waves flatten (several days later) </li></ul><ul><li>Stage III: T waves invert (weeks later) </li></ul><ul><li>Stage IV: T waves revert to normal (weeks or months later)) </li></ul><ul><li>Other changes: Large effusion can cause both reduced voltage and electrical alternans. </li></ul>
    14. 14. EKG of Acute pericarditis (Stage I)
    15. 15. Acute inferior myocardial infarction
    16. 16. Laboratory findings --- Chest x-ray film <ul><li>Cardiac shadow has an enlarged “water-bottle” appearance. </li></ul><ul><li>Clear lung field. </li></ul><ul><li>Cardiac shadow changes with postures. </li></ul>
    17. 17. Laboratory findings ---Echocardiography <ul><li>This is the best noninvasive investigation for confirming diagnosis of a pericardial effusion </li></ul>
    18. 18. Laboratory findings --- Pericardiocentesis <ul><li>1.Pericardiocentesis can help to make diagnosis . </li></ul><ul><ul><li>Fluid should be sent for culture and assay </li></ul></ul><ul><ul><ul><li>Protein, glucose and LDH assays : LDH, glucose and protein determine if fluid is a transudate or exudate; </li></ul></ul></ul><ul><ul><ul><li>Cytology and tumor marker : CEA, AFP, CA125 and so on; </li></ul></ul></ul><ul><ul><ul><li>ANA assay : if collagen vascular disease is suspected. </li></ul></ul></ul><ul><li>2. Pericardiocentesis can relieve the pressure of pericardial cavity. </li></ul>
    19. 19. Diagnosis of Acute Pericarditis <ul><li>Chest pain aggravated by coughing, inspiration,or recumbency </li></ul><ul><li>Pericardial friction rub on auscultation </li></ul><ul><li>Charateristic EKG changes </li></ul><ul><li>Chest X-ray and UCG may find pericardial effusion </li></ul>
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. Treatment <ul><li>1.Etiology treatment </li></ul><ul><ul><li>Bacterial infection </li></ul></ul><ul><ul><li>Viral infection </li></ul></ul><ul><ul><li>TB </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Collagen vascular disease </li></ul></ul><ul><li>2. Relieving pain and inflammation: </li></ul><ul><ul><li>NSAIDs and steroids </li></ul></ul><ul><li>3.If symptoms are severe, pericardiocentesis is indicated to remove fluid. </li></ul>
    24. 24. Constrictive pericarditis
    25. 25. Definition <ul><li>Constrictive pericarditis is a thickening and fibrosis of the pericardium that occurs long after an acute episode of pericarditis. It produces decreased diastolic filling . </li></ul>
    26. 26. Etiology <ul><ul><li>TB is a leading cause in underdeveloped countries including China, about 40%. </li></ul></ul><ul><ul><li>Others: Purulent inflammation, Pericardial injury, Radiation therapy etc. </li></ul></ul>
    27. 27. Clinical Manifestations <ul><li>Symptoms: </li></ul><ul><li>Dyspnea on exertion and orthopnea </li></ul><ul><li>Other symptoms </li></ul><ul><ul><li>Hypodynamia </li></ul></ul><ul><ul><li>Big belly </li></ul></ul><ul><li>Physical Signs: </li></ul><ul><li>Distended jugular vein </li></ul><ul><li>Kussmaul sign </li></ul><ul><li>Edema, ascites </li></ul><ul><li>Heart sounds are distant and a pericardial knock is detected after S 2 </li></ul><ul><li>SBP↓ 、 DBP↑ 、 pulse pressure↓ </li></ul>
    28. 28. Laboratory findings <ul><li>Radiography/CT/MRI </li></ul><ul><ul><li>Pericardial calcification </li></ul></ul><ul><li>ECG </li></ul><ul><ul><li>Low voltage in limb leads </li></ul></ul><ul><ul><li>T wave is low or upside down </li></ul></ul><ul><ul><li>Atrial arrhythmias. </li></ul></ul><ul><li>Echocardiography </li></ul><ul><ul><li>Pericardial thickening in most cases can be demonstrated </li></ul></ul>
    29. 30. Diagnosis of Constrictive pericarditis <ul><li>1.Congestion of systemic circulation: distended </li></ul><ul><li>jugular vein, edema </li></ul><ul><li>2.Pericardial knock on auscultation </li></ul><ul><li>3.X-ray,Magnetic resonance, computed </li></ul><ul><li>tomography, or echocardiographic imaging </li></ul><ul><li>showing a thickened or calcified pericardium </li></ul>
    30. 31. Treatment <ul><li>1.Pericardiectomy as early as possible. </li></ul><ul><li>2.Antituberculous therapy may be required if the underlying cause is tuberculosis and should be continued for 1 year. </li></ul>
    31. 32. Thank you! Mobile phone:13538711610 Email:zwtlxy@tom.com 曾武涛