A Family Doctor's Tale - PERICARDITIS

DOC I HAVE PERICARDITIS

Pericarditis is the inflammation of the pericardiac sac surrounding the heart resulting in the pericardiac fluid compressing the heart.

All such cases of pericarditis should be hospitalized and where there is fever treated with antibiotic and NSAID pain killers.

In severe cases fluid from the pericardiac sac should withdrawn with a needle.

Very rarely surgery may be needed.


Pericarditis is a heart condition where there is inflammation of the pericardiac sac surrounding the heart and roots of the great vessels coming from the heart.

Pericarditis is the most common of all pericardial condition

It is more common in females than males



Pericarditis is caused by:

A.Infections
1.Bacterial- streptococcus

2.Viral - adenovirus, enterovirus, cytomegalovirus, influenza virus, hepatitis B virus, and herpes simplex virus

3.mycotic

4.tuberculosis

B.Non- infection:
1.Autoimmune diseases include:

a.Rheumatic fever

b.rheumatoid arthritis

c.systemic lupus erythrematosis

d.drug induced

2.Neoplastic

3.Uremia

4.myxedema

5.trauma

6.myocardial infarction

7.myocarditis,

8.dissecting aortic aneurysm,

9.radiation



Symptoms:

1.Chest pain of sudden onset in the anterior chest

2.Pain is sharp and becomes worse with inspiration due to pleural inflammation.

3.Pain is relieved with sitting up and leaning forward and become worse on lying down

4.Pericardial rub is a diagnostic sign of acute pericarditis.
Absence of this sign does not mean that it is not pericarditis.

This rub is best heard at the left sternal border as a squeaky or scratching sound using the diaphragm of the stethoscope.

The pericardial rub is due to the friction generated by the two inflamed layers of the pericardium.

5.Fever may be present.

Diagnosis of Pericarditis is made by:


1. History and physical examination
chest pain, Pericarditis episodes

2.Blood tests:
a. A Complete Blood Count may show an elevated white count.

b. serum C-reactive protein may be elevated.

c.increase in serum creatine kinase MB  and cardiac troponin I ( both of which are also markers for myocardial injury.

3.Electrocardiogram
ECG changes in acute pericarditis show inflammation of the epicardium (the layer directly surrounding the heart).

Typical ECG changes in acute pericarditis are:

stage 1 -- diffuse, positive, ST elevations with reciprocal ST depression in aVR and V1.
stage 2 -- normalization of ST and PR deviations
stage 3 -- diffuse T wave inversions
stage 4 -- ECG becomes normal OR T waves may be indefinitely inverted

4.Echocardiography
Usually normal in acute pericarditis.

It can reveal pericardial effusion, the presence of which supports the diagnosis.

5. Chest X-ray
Chest X-ray is generally only performed if a pulmonary cause of Pericarditis is suggested.

It is normal in acute pericarditis, but can reveal cardiomegaly (enlarged heart) if the pericardial effusion is more than 200 mL.

6.Cardiac catherisation -Coronary angiography in those patients should indicated normal vascular perfusion.

7. Pericardial fluid examination and biopsy- rarely done except for confirmation of neoplasm and tuberculosis.

Complications of Pericarditis are:


Cardiac tamponade is accumulation of fluid in the pericardial space to cause blockage to the inflow of blood to the heart.

Cardiac tamponade is an emergency and must be treated urgently.

Treatment of Pericarditis :


Patients with uncomplicated acute pericarditis can be treated by a heart specialist on outpatient basis.

Those with high risk factors will need to be admitted to hospital:

1.sudden onset
2.high fever
3.leukocytosis
4.presence of cardiac tamponade
5.large pericardial effusion (echo-free space > 20 mm) resistant to NSAID treatment
6.low immunity
7.oral anticoagulation therapy
8.acute trauma

Removal of the pericardial fluid:
Pericardiocentesis is done to remove the fluid in a pericardial effusion  through a needle.
It is performed under the following conditions:

moderate or severe cardiac tamponade
diagnosis of suspected purulent, tuberculosis, or neoplastic pericarditis
persistent pericardial effusion
viral or idiopathic pericarditis.

Treatment of underlying cause :


a.In idiopathic or viral pericarditis, NSAID(ibuprofen) is the mainstay treatment.

Goal of therapy is to reduce pain and inflammation.

Failure to respond to NSAIDs within one week (indicated by persistence of fever, worsening of condition, new pericardial effusion, or continuing chest pain) indicate the cause is not viral or idiopathic.

Colchicine can be used alone or in conjunction with NSAIDs in prevention of recurrent pericarditis and treatment of recurrent pericarditis.

b.Anti tuberculous treatment must be given to Tuberculous patients.

c.Chemotherapy is given for cancer patients.

d.Autoimmune disease:
Systemic corticosteroids are usually reserved for those with autoimmune disease.

Surgery
Pericardial window or removal of pericardium is done especially when there is possiblity of cardiac tamponade.

Proteolytic enzymes:
Proteolytic enzymes is used to dissolve the fluid in the pericardial sac.



Most cases of patients have recurrent pericarditis and become chronic after acute episode.

Response to surgery may not be very satisfactory especially with long standing chronic pericarditis.



Rest and a healthy lifestyle may help to prevent an onset or recurrence of Pericarditis.

Avoid stress and anxiety.