Pericarditis

By:

Azizah Mohammed Melebary

Introduction

Pericarditis is a swelling and irritation of the pericardium, the thin sac-like membrane that surrounds the heart.

Pericarditis often causes chest pain and sometimes other symptoms. Pericarditis may be acute or chronic.

The sharp chest pain associated with acute pericarditis occurs when the pericardium rubs against the heart's outer layer.

Mild cases may improve on their own. Treatment for more-severe cases may include medications and, rarely, surgery. Early diagnosis and treatment may help to reduce the risk of long-term complications.

Pericarditis most often affects men aged 20-50, usually following respiratory infections.

Cont.

Signs and symptoms

In case of acute pericarditis, the most common symptom is sharp, stabbing chest pain behind the breastbone or in the left side of the chest. However, some people with acute pericarditis describe their chest pain as dull, achy or pressure-like instead, and of varying intensity.

Cont.

The sharp pain may travel into the left shoulder and neck. It often intensifies when lie down or inhale deeply. Sitting up and leaning forward can often ease the pain. At times, it may be difficult to distinguish pericardial pain from the pain that occurs with a heart attack.

Other signs and symptoms often associated with pericarditis include:

• Shortness of breath when

• Low-grade fever

• An overall sense of weakness, fatigue or feeling sick

• Dry cough

• Abdominal or leg swelling

Causes:

• Under normal circumstances, the two-layered pericardial sac that surrounds the heart contains a small amount of lubricating fluid.

• In pericarditis the sac becomes inflamed and the resulting friction from the inflamed sac rubbing against the outer layer of the heart leads to chest pain.

• In some cases the amount of fluid contained in the pericardial sac may increase, causing what is called pericardial effusion.

Cont.

• The cause of pericarditis is often hard to determine. In most cases doctors are either unable to determine a cause (idiopathic) or suspect a viral infection.

• Pericarditis can also develop shortly after a major heart attack due to the irritation of the underlying damaged heart muscle. In addition, a delayed form of pericarditis may occur weeks after a heart attack or heart surgery because of antibody formation. This delayed pericarditis is known as Dressler's syndrome.

Cont.

• Many experts believe Dressler's syndrome is due to an autoimmune response, a mistaken inflammatory response by the body to its own tissues.

Other causes of pericarditis include:

• Systemic inflammatory disorders. These may include lupus and rheumatoid arthritis.

• Trauma. Injury to the heart or chest may occur as a result of a motor vehicle or other accident.

• Other health disorders. These may include kidney failure, AIDS, tuberculosis and cancer.

• Certain medications. Some medications can cause pericarditis, although this is unusual.

Screening and diagnosis

• The doctor will likely begin by taking medical history and asking questions about the chest pain and other symptoms.

• Medical history and physical examination. The doctor may ask whether he have recently experienced an upper respiratory infection or a flu-like sickness, and whether the chest pain worsens when he lie down or when he take a breath.

Cont.

• Physical exam. Pt. may also undergo a physical examination and a review of whether he have medical conditions, such as kidney disease, a recent heart attack or chest trauma.

• Heart sounds. The doctor may place a stethoscope on chest to listen for the sounds characteristic of pericarditis, which are made when the pericardium rubs against the outer layer of the heart. Some doctors describe this characteristic noise as pericardial rub.

the following diagnostic procedures:

• Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to skin to measure the electrical impulses given off by heart. Impulses are recorded as waves displayed on a monitor or printed on paper. Certain ECG results may indicate pericarditis.

• Chest X-ray. With an X-ray of chest, The doctor can study the size and shape of heart. Images of heart may show an enlarged heart if excess fluid has accumulated in the pericardium.

Cont.

• Echocardiogram. This test uses high-frequency sound waves to create a picture of your heart and its structures, including fluid accumulation in the pericardium. The doctor can view and analyze this image on a monitor.

Cont.• Computerized tomography (CT). This X-ray

technique can produce more-detailed images of heart and the pericardium than would conventional X-ray studies. CT scanning may also be performed to exclude other causes of acute chest pain, such as blood clots in the lung arteries (pulmonary emboli) or a tear in the aorta (aortic dissection).

• Magnetic resonance imaging (MRI). This technique uses a magnetic field and radio waves to create cross-sectional images of heart that can reveal

Complications

• Constrictive pericarditis. Some people with pericarditis, particularly those with long-term inflammation and chronic recurrences, can develop permanent thickening, scarring and contracture of the pericardium.

In these people, the pericardium loses much of its elasticity and resembles a rigid case that's tight around the heart, which keeps the heart from working properly. This condition is called constrictive pericarditis and often leads to severe swelling of the legs and abdomen, as well as shortness of breath.

Cont.• Cardiac tamponade. When too much fluid

collects in the pericardium, a condition called cardiac tamponade can develop. Excess fluid puts pressure on the heart and doesn't allow it to fill properly. That means less blood leaves the heart, which causes a dramatic drop in blood pressure. If left untreated, cardiac tamponade can be fatal.

Early diagnosis and treatment of pericarditis usually reduces the risk of the long-term complications.

Treatment

Deciding upon treatment for pericarditis will likely involve consideration of the underlying cause as well as the severity. Mild cases of pericarditis may get better on their own without treatment.

Rest and medications

• The doctor may recommend bed rest until the Pt. feeling better.

• Medications to reduce the inflammation and swelling associated with pericarditis are often prescribed.

• Most pain associated with pericarditis responds well to treatment with aspirin or another nonsteroidal anti-inflammatory drug (NSAID).

• If pain is severe, you might need stronger pain medications, such as a narcotic, for a short time.

• Diuretics may be used to remove excess fluid accumulated in the pericardial sac.

• Acute episodes of pericarditis typically last from one to three weeks, but future episodes can occur. About one in five people with pericarditis has a recurrence within months of the original episode.

• People who have repeated episodes of pericarditis are often treated with a drug called colchicine, and sometimes steroid medications are used.

• When a bacterial infection is the underlying cause of pericarditis, must be treated with antibiotics and drainage if necessary.

Hospitalization and procedures

It will likely need hospitalization if the doctor suspects cardiac tamponade, a potentially dangerous complication of pericarditis. When cardiac tamponade is present, It may undergo a technique called pericardiocentesis. In some cases of severe pericarditis, the doctor might suggest surgically removing the pericardium (pericardiectomy).

Cont.

• Pericardiocentesis. In this procedure, a doctor uses a sterile needle or a small tube (catheter) to remove and drain the excess fluid from the pericardial cavity. It will need a local anesthetic before undergoing pericardiocentesis, which is often done with echocardiogram monitoring and ultrasound guidance. This drainage may continue for several days during the course of hospitalization.

Cont.• Pericardiectomy. If diagnosis with

constrictive pericarditis, It may need to undergo a surgical procedure (pericardiectomy) to remove the entire pericardium that has become rigid and is compromising the functioning of the heart.

• If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended.

Expectations (prognosis)    

• Pericarditis can range from mild cases that resolve on their own to life-threatening cases complicated by significant fluid buildup around the heart and poor heart function. The outcome is good if the disorder is treated promptly. Most people recover in 2 weeks to 3 months.

CASE PRESENTATION:

MR no:619132

Pt. name: Adel Al-Gharbawi.

Age:36 Y Wt. 77.7kg

Admission Date: 13/5/2007

CC: Adel 37yrs old single presented to ER with Hx of sever chest pain & S.O.B for 10 days before admission.

Cont.

Past medical Hx:Patient was not known case for any previous

medical illness, patient was presented to ER with Hx of chest pain burning in nature associated with S.O.B .

Family and social Hx:singleAllergy:NKA

Cont.

Investigation:Patient is conscious, alert, no pallor, no jaundice, or

cyanosis.O2 saturation: 97%CVS: S1+ S2+ pansystolic murmur radiated to axilla.JVP: no LL edema.Abdomen: soft, lax, NO organomegaly. CNS: grossly intact.NO Hx of fever or headache. NO Hx of joint pain.

Vital Signs/ Laboratory Data:

Date27/529/531/52/6

Vital sign

Wt.77.7 Kg77 Kg

Temp.373636.736.8

BP110/6590/6095/5785/60

Pulse82798099

RR.20222019

Blood

PH

Date27/529/531/52/6

PCO24.25

PO28.87

HCO324.0

U&E

Na136

CL101

K4.1

BUN4.6

Cr104

Enzymes

ANA-ve

Date27/529/531/52/6

AF< 9.5

CK67433236

LDH319↑305↑287↑270↑

Tropenin0.71↑0.55↑0.41↑0.41↑

AST182018

CRP20.8↑

ESR2015

5-HIAAPending

Current Drug Therapy:

DrugStarting day Monitoring

Claritine 10mg PO BID12/5 Loratadined, long acting, non sedating.

Pantoprazol 40mg PO OD13/5

Aspirin 300mg PO OD14/5 GI distress

Clexane 60mg SC BID17/5 Platelet count. aPTT, signs of bleeding.

Pulmicort Q8hr30/5

Atrovent Q8hr30/5. dry mouth, nausea, constipation, & headach.

Motilum 10mg PO OD18/5

Nitroglycerine patch 5mg 15/5 BP, heart rate.

Fursemide 20mg PO OD2/6 Wt. and I& O daily, BP, serum electrolytes, renal function, monitor hearing.

Bisoprolol 2.5mg PO OD27/5 BP, EKG, neurological status.

Plan:

• The impression that patient have Pericardities (viral), Give analgesic drug to controle the chest pain.

• At 30/5 Pt started with upper respiratory tract infection (URTIs), and give Pulmicort & Atrovent.

• Pt still complaining from chest pain but it is improving than before, The doctor orders the MRI of the chest.

• The doctor suggest to see the case by haematology to rule out lymphoma. And maeasure 5-HIAA level.

Assessment:

• The prognosis for people who have pericardities depends on the cause. When pericardities is caused by a virus or when the cause is not apparent, recovery usually takes 1-3 weeks.

• Drugs that cause pericardities are discontinued whenever possible.

• Frequently must measure serum creatinin to rule out kidney failure.

• Bisoprolol in this case has no any benefit, & this Pt. have ↓ in BP that must be concern.

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• http://www.mayoclinic.com/health/pericarditis/DS00505/DSECTION=7