Myocardial and pericardial disorders Flashcards
Normal Pericardium Definition
- double-walled sac
- surrounds the heart and great vessels origin
Normal Pericardium Components
Two layers
- Fibrous Parietal layer (2 mm thick, accelular)
- Serous Visceral layer = epicardium- contact with mioyocardium
- Pericardial cavity
- Pericardial fluid → 15 –50 ml (serous fluid- plasma ultrafiltrate)
→ secreted / absorbed continuously
→ 800 ml/day
! well Innervated → inflammation may produce severe pain
→ trigger vagus mediated reflexes
PHYSIOLOGY OF THE PERICARDIUM
PERICARDIUM ROLES
- Fixes the heart to the mediastinum (ligamentous attachments to the diaphragm, sternum, and other structures)
- Limits friction between the heart and surrounding structures
- prevents displacement of the heart and kinking of the great vessels
- Provides lubrication for the heart
- Protection against extension of mediastinal infections
- Delaying extension of infections / malignancy
- HEMODYNAMIC Role → distribution of the hydrostatic forces
- Coupling of ventricular diastolic pressures
- Facilitating atrial filling in ventricular systole
- Increasing blood volume in ventricular systole
- Preventing acute dilations of heart
Classical pericardial syndromes
- Pericarditis (Inflammatory Diseases)
- Pericardial effusion
- Cardiac tamponade
- Constrictive pericarditis
- Other
• Congenital absence of pericardium
• Tumors
Acute pericarditis Definition
Syndrome due to Pericardial Inflammation
- without pericardial effusion
- with pericardial effusion
Not causing compression
Causing compression
ESC Classification
- Acute pericarditis : New-onset pericarditis
- Incessant : Lasting for >4–6 Weeks but <3
Months without remission - Chronic Pericarditis : lasting for >3 Months
- Recurrent Reccurence of pericarditis after a documented first episode of acute pericarditis and a
symptom-free interval of 4–6 Weeks or longer
Pericarditis- Etiologic Classification
1.Infectious Pericarditis
2.Non - Infectious Pericarditis
3. Pericarditis most likely related to hypersensitivity or
autoimmunity
Infectious Pericarditis
- Viral (coxsackievirus A and B, echovirus, mumps, adenovirus, HIV)
- Bacterial → Pyogenic (pneumococcus, streptococcus, staphylococcus, etc)
- Tuberculous
- Fungal
- Other infections (syphilitic, protozoal, parasitic)
Non- Infectious Pericarditis
- Acute myocardial infarction
- Uremia
- Neoplasia
a) Primary tumors (benign or malignant, mesothelioma)
b) Tumors metastatic to pericardium (lung and breast cancer, lymphoma, leukemia) - Myxedema
- Chylopericardium
- Trauma
a) Penetrating chest wall
b) Nonpenetrating - Aortic dissection (with leakage into pericardial sac)
- Postirradiation
- Familial Mediterranean fever
10.Acute idiopathic
11.Whipple’s disease
12.Sarcoidosis
III. Pericarditis most
Pericarditis most likely related to hypersensitivity or
autoimmunity
- Rheumatic fever
- Collagen vascular disease (systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, scleroderma, granulomatosis with polyangiitis (Wegener’s)
- Drug-induced (e.g., hydralazine, phenytoin, Isoniazide, anticoagulants)
- Post-cardiac injury
a) Postmyocardial infarction (Dressler’s syndrome)
b) Postpericardiotomy
c) Posttraumatic
Pericarditis
Clinical diagnosis
At least 2 out of 4 following criteria:
(1) Pericarditic Chest Pain
(2) Pericardial Rubs
(3) Dynamic Ecg changes (New widespread ST-
elevation or PR depression)
(4) Evidence of Pericardial effusion (new or worsening)
Additional supporting findings: - ↑ marker of inflammation CRP, erythrocyte sedimentation rate, and WBC - Evidence of pericardial inflammation (imaging technique: CT, CMR)
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
CLINICAL aspect
- Symptoms suggestive for etiology (ex.: fever, myalgia)
- Typical features
- Nerves compression / iritation
Symptoms
Dyspnea Cough
Dysphagia Hiccup
Dysphonia Nausea
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
(1) CHEST PAIN characteristics
- Localization Retrosternal
- Left precordial area
- Referred to : Neck base, left Trapeziums ridge, Left arm
- Aggravated by : Inspiration, coughing, deglutition, changes in body position, dorsal decubitus
- Relieved by : Leaning Forward, Sitting Up
Duration Hours, Days
Intensity ↑ → Infectious AP - Absent → fluid develops within long time
(neopasms, tuberculosis, uremia)
Differentiation of pericarditis from
myocardial ischemia or infarction
image slide 7
Pericarditis
Differential diagnosis
- AMI
- Aortic dissection
- Pulmonary embolism
- Pneumonia
- Mediastinitis
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
PHYSICAL EXAMINATION
Position: upright and leaning forward position
Auscultation (diagnostic feature):
(2) PERICARDIAL FRICTION RUB
- Does not respect cardiac cycle
- It’s over the cardiac sounds
- Superficial
- Inconstant
- May disappear (with great quantity of fluid)
- Characteristics : high-pitched, scratching, grating
Percution Cardiac dullness:
Normal (pericarditis without effusion or↓↓effusion) OR
Increased (pericarditis with large effusion)
Palpation: Apex beat
Interior of the dullness (if fluid +++) OR
Normal in dry pericarditis
Auscultation (other):
Cardiac sounds
Faint ( if fluid +++ ) OR
Normal ( if no fluid or ↓↓↓ fluid)
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
(3) Ecg - dynamic changes
- PR depression
- ST pattern - I. ST elevation +Twave, STE without ST
- depression, in all
(dynamic) leads, except V1 and aVR - II. Isoelectric ST segment and flattened T wave
- III. Inverted T waves later
- IV. normalisation Ecg
- ST-T Changes
- QRS ± reduction in voltage of the QRS complexes
- electrical alternans (in Cardiac Tamponade)
- Rhythm disorders: sinus tachycardia (AFi, AFl)
- Conduction disorders: usually with myocarditis
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
(4) Pericardial effusion evidence
Physical exam Echocardiography Chest Radiography ─ An increased cardiothoracic ratio occurs only with pericardial effusions > 200- 300 ml
Radioscopy
─ Diminished pulsations of the cardiac border
ECHOCARDIOGRAPHY
↑ Specificity, Sensibility →“gold standard”
has replaced other methods
• M mode detects quantity of fluid as small as 20 ml
• 2D detects circumferential / localized pericardial effusion
Detects
• Variable amount of Pericardial effusion (if present)
An ECHO-FREE space between the epicardium and
pericardium behind LV, in front of RV
( !!!! If this space is small and only in systole =
PHYSIOLOGICAL)
- If large fluid present →swinging heart
- Thickened and hyper-reflective pericardial layers
- Wall motion abnormalities in myo-pericarditis
- Normal in some patients
II. PERICARDIAL EFFUSION
Definition
- ↑ production of pericardial fluid by inflammatory processes
(exudate) - ↓ reabsorption due to a ↑systemic venous pressure (transudate)
II. PERICARDIAL EFFUSION
Classification
Onset
− Acute or subacute
− Chronic >3 months
Distribution
− Circumferential
− Loculated
Haemodynamic impact
− None
− Cardiac tamponade
− Effusive-constrictive
Size (semiquantitative echo)
− Mild (<10 mm)
− Moderate (10–20 mm)
− Large (>20 mm)
II. PERICARDIAL EFFUSION
Clinical aspect
- Acute effusive pericarditis without compression of the heart → See previous text for clinical aspect
- Pericardial effusions within specific etiologies have the clinical aspect of the basic etiology
- Cardiac tamponade → See next text
ACUTE PERICARDITIS
Fibrinous or Effusive
Without compression of the heart
(3) Ecg - dynamic changes
- PR depression
- ST pattern - I. ST elevation +Twave, STE without ST
- depression, in all
(dynamic) leads, except V1 and aVR - II. Isoelectric ST segment and flattened T wave
- III. Inverted T waves later
- IV. normalisation Ecg
- ST-T Changes
- QRS ± reduction in voltage of the QRS complexes
- electrical alternans (in Cardiac Tamponade)
- Rhythm disorders: sinus tachycardia (AFi, AFl)
- Conduction disorders: usually with myocarditis
III. CARDIAC TAMPONADE
Definition:
Large Effusive Pericarditis that compress the heart and affect ventricular diastolic filling with severe hemodynamic consequences.
!! A Lifethreatening cardiovascular emergency