Pericardial Diseases PDF

# Pericardial diseases ## 1. Acute pericarditis: ### Causes: - Idiopathic - Infection [viral (most common); Coxsackie virus, Fungal, or bacterial; TB] - Uremia (uremic pericarditis in renal failure is an indication for dialysis) - Hypothyroidism - MI - Autoimmune arthritis and SLE ### Clinical presentation: - **Symptoms:** pleuritic chest pain that gets worse by lying flat and relieved by sitting forward - **Signs:** O/E: Pericardial friction rubs ### Investigations: - CBC, ESR - ECG: - Global concave (saddle shaped) ST segment elevation - But the most specific ECG finding is PR depression ### Management - **First line:** NSAID (Ibuprofen) + treatment of underlying cause - **Second line:** colchicine (colchicine prevents WBCs migration to site of inflammation) + treat underlying cause - **Steroids:** are only given in severe cases because it decreases immunity ## 2. Pericardial effusion: ### Causes: - Same as acute pericarditis ### Clinical features: - **Ewart sign:** bronchial breathing in the base of Lt lung, (because the pericardium contains fluids that compress the base of Lt lung (Lt looks like it is collapsed)) ### Diagnosis: - **ECG:** two findings: - Low voltage QRS - Electrical Alternans: This short QRS complex has an altered height sometimes it is short and sometimes it is even shorter, this is because the heart is floating on water and has an instable, fluctuating position - **CXR** enlarged heart (cardiomegaly) - **Echo:** the DIAGNOSTIC test, there is echo free zone around the heart ### Treatment: - By treating the underlying cause - Pericardiocentesis may be used as diagnostic and therapeutic ## 3. Constrictive pericarditis: ### Definition: - Stiffness of the wall of pericardium that limits contractility of the heart ### Clinical features: - Symptoms & Signs of Right sided HF. ### Note: - Constrictive pericarditis and Restrictive cardiomyopathy have the same clinical presentation of Rt sided heart failure. - **Kussmaul's sign:** paradoxical rise of JVP with inspiration [Normally JVP decreases with inspiration because the intrathoracic pressure becomes negative venous return increases and JVP decreases. But in constrictive pericarditis stiffness prevents the increase of venous return] ### Investigations: - imaging *CXR, CT, MRI → Calcified pericardium. ### Management: - pericardiectomy ## 4. Cardiac tamponade: ### Causes - Aortic dissection - Trauma - Post cardiac biopsy - Anticoagulants (Warfarin) ### Clinical features: - **Beck's triad:** - Raised JVP - Low BP - Muffled heart sounds - **Kussmaul's sign** is present - **Pulsus paradoxus:** [Normally with inspiration the pulse and blood pressure drop, because the decrease in intrathoracic pressure increases venous return, and blood accumulate in the heart. But this drop in BP is NEVER larger than 10 mmHg, (for example if it was 90, with inspiration it normally becomes 80 or above but never less than that). In pulsus paradoxus there is weak impalpable pulse or the drop in BP is more than 10 mmHg). So, pulsus paradoxus is an exaggeration of a normal response. ### Investigations - Same as investigations of pericardial effusion and similar findings (both of them are due to fluid accumulation) ### Treatment: - Pericardiocentesis (drainage) + treatment of underlying cause # Cardiomyopathies ## 1. Dilated cardiomyopathy (DCM): - Is global enlargement and dilatation of heart chambers. ### Causes: - Idiopathic (most common) - Pregnancy (peri-partum and post-partum dilated cardiomyopathy) - Alcoholism (thiamine (Vitamin B1) deficiency) - Beriberi (thiamine deficiency) - Hemochromatosis - Drugs (doxorubicin (a drug used in treatment of cancer)) ### Genetics: - X-linked - Duchenne Muscular Dystrophy ### Clinical features: - Symptoms and signs of Congestive heart failure - Systolic Failure (decreased Ejection Fraction) - Apex is displaced - Systolic murmur (mitial regurgitation) ### Diagnosis: - By ECHO: there is enlarged heart ### Complications: - Thrombosis and embolization; due to stasis of blood that occurs due to weak contraction - Arrhythmia: when the dilatation of chambers involves the conductive system ### Treatment: - Treatment of heart failure - ICD (implantable cardiac defibrillation) can be done. - Resynchronization therapy - Cardiac transplantation ### Note: - In Dilated cardiomyopathy there are signs and symptoms of congestive heart failure. - In Restrictive cardiomyopathy there are signs and symptoms of Rt side heart failure. ### Note: - Dilated cardiomyopathy is the only cardiomyopathy in which the type of heart failure is systolic. - In restrictive cardiomyopathy and HOCM it is diastolic. ## 2. Restrictive cardiomyopathy: ### Causes: - Idiopathic - Amyloidosis (the deposits in Amyloidosis decrease efficacy of diastole) - Sarcoidosis - Haemochromatosis - Endo-myocardial fibrosis and fibro-elastosis (occurs in children): fibrosis of endocardium and myocardium - Loffler's syndrome (there is eosinophilic infiltrate that causes deposition similar to that of amyloidosis) ### Clinical features:: - Similar to Rt side heart failure - There is Diastolic Failure. ### Diagnosis: - Myocardial biopsy through cardiac Catheterization ### Management: - Cardiac transplantation. - Prognosis is very poor. ## 3. Hypertrophic Obstructive cardiomyopathy [HOCM]: ### Causes: - Autosomal dominant mutations in sarcolemma proteins. - This mutation is associated with Friedrich's Ataxia. ### Clinical features: - **Symptoms:** same triad of aortic stenosis [Syncope on exertion, Angina, and Dyspnea] - **Signs:** - Pulse: jerky pulse - Apex: double apex beat, due to obstruction. - Ejection systolic murmur at the lower part of sternum | Maneuver | HOCM | AS | |-----------|-------|-----| | Valsalva maneuver and standing from sitting | Increase murmur | Decrease murmur| | Squatting | Decrease murmur | Increases murmur| ### Diagnosis: - By Echo: Mnemonic: MR SAM ASH ### Note: - The cause of death in pt with Friedrich's ataxia is HOCM - Duchenne causes DCM ### Note: - Vasodilators are contra-indicated in obstructive lesions (HOCM and AS). ### 1. Asymmetrical septal hypertrophy. ### 2. Systolic Anterior motion of mitral leaflet. ### 3. Functional mitral regurgitation. ### Exercise test (measurement of BP during exercise): - to assess risk of SCD. ### Halter ECG monitoring (24 hrs ECG monitoring): - to assess risk of SCD - HOCM is the most common cause of sudden cardiac death in young athletes. ### Factors that Increase risk of sudden cardiac death (SCD): - Young age (< 14 yrs) - Family history of sudden cardiac death - Syncope at presentation - Septum thickness more than 3 cm by echo (most important factor) - V. Exercise test: abnormal BP changes during exercise - Halter monitoring: Short running of ventricular tachycardia ### Management: - **Medical:** - Most important drug is ß blockers (because they have angina) -**Surgical;** - Septal myomectomy - ICD if there is high risk of sudden cardiac death # Myocarditis - Inflammation of the cardiac myocytes. ### Causes: - **Viral:** coxsackievirus B, parvovirus B19, human herpesvirus-6, adenovirus, and HIV - **Bacteria:** Diphteria ### Clinical presentation: - Fever and signs and symptoms characteristic of heart failure - History of viral prodrome preceding the development of heart failure (upper respiratory infection 3 weeks before his presentation) ### Diagnostic: - Increased cardiac biomarker concentrations (troponin) - Normal ECG - Normal chest x-rays or may show pulmonary edema or pleural effusions depending on volume status ### Treatment: - Generally supportive - Some patients may require diuresis, and depending on severity, mechanical or pharmacologic inotropic support or transplant. # Ischemic heart diseases - Ischemic heart diseases present clinically Cardiac pain. ### Causes of cardiac pain: - Decreased blood supply to the heart - Increased demands - Decreased oxygen carrying capacity of blood ### Ischemic heart diseases include: - Stable angina - Variant angina - Acute coronary syndrome (ACS): - Unstable angina - Non ST segment elevation myocardial infarction (NSTEMI) - ST segment elevation myocardial infarction (STEMI) - Sudden cardiac death (SCD) ## Criteria of Cardiac pain: - Central, crushing, radiating to jaw or left arm - Aggravated by exercise, stress, emotions, and cold - Relieved by rest or sublingual nitrates - If the above 3 criteria are present: typical cardiac pain - If 2 present: atypical cardiac pain - If 1 or less: Non cardiac pain "look for another cause". ## 1. Stable angina: - Cardiac pain up to 15 min Relieved by rest or sublingual nitrates - **Pt with angina who has known history of CAD:** - If there is typical cardiac pain → start treatment immediately, no need to investigate - If there is Atypical cardiac pain → do functional studies: - Exercise Echo - Thallium scan (also called myocardial perfusion scan): decrease perfusion - Exercise ECG: not diagnostic, just gives probability of having angina. - **Pt with angina who does not has any history of CAD:** We should calculate cardiovascular risk as follow: - Cardiovascular risk > 90% → start treatment immediately. - Cardiovascular risk 90-61% → do angiography. ### Notes: - Male pt older than 70 yrs: you should start treatment immediately. - Female pt older than 70 yrs: do Angiography - Cardiovascular risk 60-30% → do functional studies. - Cardiovascular risk 29-10% → do calcium CT score. - Cardiovascular risk < 10% → consider another diagnosis. ### Management (long term) - **Life style modification:** Diet, exercise, quit bad habits, Control risk factors (DM, HTN, hyperlipidemia) - **Symptomatic drugs (monotherapy):** - Sublingual nitrate (GTN): Sublingual at home or as Spray, given when symptoms occur or as Prophylaxis - B blockers - Anti-platelet therapy: e.g. aspirin (to decrease mortality) - **If not controlled by monotherapy:** - Add Calcium channel blockers (CCB) - **The invasive procedures are:** - PCI - Coronary Artery Bypass Grafting (CABG) ### Cessation of smoking - Is the most important measure for the prevention of coronary artery disease. ## 2. Variant "Prinzmetal" angina: - Caused by sudden spasm of coronary artery - **Clinically:** Pt is usually female, angina at night (at rest) - **ECG:** shows ST elevation ### Management: - CCBs ### The following drugs are contra-indicated in Variant angina: - Aspirin - B blockers (caused spasm of coronary artery) - B blockers ## 3. Acute Coronary Syndrome (ACS): ### D.D. of ACS: - Unstable angina - Non ST segment elevation myocardial infarction (NSTEMI) - ST segment elevation myocardial infarction (STEMI) ***In MI cardiac pain is > 20 min.*** - In MI there is myocardial cell death, cardiac enzymes leak, and can be detected in plasma. - So, if you want to differentiate between them: - In Unstable angina: there is No ST elevation and No cardiac markers. - In NSTEMI: there in No ST elevation but cardiac markers are elevated. - In STEMI: there is ST elevation and cardiac markers are elevated. ## Myocardial Infarction (MI): ### Types of STEMI : - **Anterior MI:** - Blockage is in the Lt anterior descending artery - It is the most common type - ECG changes: ST elevation in chest leads from V1 to V4. - **Lateral MI:** - Blockage is in the Lt circumflex artery - ECG changes: ST elevation in the lateral leads (V5, V6, aVL, and lead I). - **Inferior MI:** - Blockage is in the Rt coronary artery - ECG changes: ST elevation in aVF, lead II, and lead III - Rt coronary artery supplies conductive system of the heart (AV node and SA node), that is why pt with inferior MI presents with heart failure with bradycardia. - **Posterior MI:** - There is ST elevation from V1 to V6 in addition to V7, V8, and V9 (these are the back leads). ### Cardiac markers: - Myoglobin is the first to rise. - Troponin is the most sensitive, drops in 7 to 10 days. - CK-MB is used to detect re-infarction because it drops rapidly (in 3 to 5 days). - So, if pt develops re-infarction do CK-MB because troponin of the previous Mi has not drop yet. ### Management of acute coronary syndrome: - **Give MONA to all patients** (Morphine, O2, Nitrates, and Aspirin). - **Then do serial ECG and serial cardiac markers, then according to result:** - If ST elevation (STEMI): after giving MONA, do reperfusion therapy: - PCI: always superior to thrombolytic therapy, the ideal time is 90 minutes. - Thrombolytic therapy: by streptokinase or by tissue plasminogen activator (tPA), the optimum time is 30 minutes. ### Note: - Streptokinase is used once a life (CABG is also used once a life). - The difference between reperfusion therapy in Ml and reperfusion therapy in stroke; is that streptokinase is used only in MI, in stroke there is NO role for streptokinase, only use tPA. - **Contra-indications to thrombolytic therapy:** - Hemorrhagic stroke EVER. - Ischemic stroke in previous 6 months. - Upper GI bleeding in previous 1 month. - Major trauma or surgery in previous 3 weeks. - Pregnancy. - CNS tumors (because they are highly vascular). - **If there is No ST elevation:** this is either NSTEMI or unstable angina, both of them has the same treatment: after giving MONA, give heparin then assess the cardiovascular risk (according to GRACE score): - If the pt has high risk GRACE score; give him glycoprotein II B/III A inhibitor, and do angiography in 4 - **Note:** High risk GRACE score: - Diabetes. - High cardiac markers. - ST depression. - Persistent or recurrent ischemia ### **3. Then give discharge medications:** - The first 4 drugs are similar in all types of ACS. - Aspirin for life. - BETA blockers for life. - ACEI for life. - Statin for life. - Clopidogrel: if STEMI give clopidogrel for 1 month, if NSTEMI or Unstable angina and the GRACE score is more than 1.5% give clopidogrel for 1 year. ### Complications of ACS: - Cardiogenic shock: treated same as heart failure. - Arrhythmias: - The most common: Bigeminal (more dangerous) and trigeminal. - The most killer arrhythmia is ventricular fibrillation. - AV block in anterior MI is dangerous and needs pacemaker. - **Pericarditis:** (Two types) - **Early (acute pericarditis):** caused by spread of inflammation from the heart to pericardium. - **Late (Dressler's syndrome):** occurs 1 to 3 weeks after MI, caused by antigen induced inflammatory response. - Mural thrombus: it occurs most commonly after anterior MI, that is why any pt with anterior MI should be given warfarin for 3 months. - Rupture of Chorda Tendineae: leading to mitral regurgitation (pan systolic murmur). - Rupture of inter-ventricular septum leading to ventricular septal defect (VSD). - Rupture of free wall of the ventricle: leading to cardiac tamponade. - Ventricular aneurysm: occurs after 6 weeks, It is diagnosed by PERSISTANT ST elevation for 6 weeks. # INFECTIVE ENDOCARDITIS (IE) - Hallmarks of IE is: Fever + murmur + spleenomagaly - Infective endocarditis is divided into Acute and Subacute: - **Acute:** - Occurs in a normal valve. - Most commonly caused by Staph Aureus. - Has poor prognosis (High mortality). - **Subacute:** - Occurs in a diseased valve. - Most commonly caused by Strep. Viridans. - Has better prognosis ### Risk factors - Previous history of IE "most important" - Heart problem (CHD, Prosthetic valve, valvular heart disease): occurs mainly in subacute IE. - Host factor (IV drug abuser or immunocompromised pt): occurs mainly in Acute IE. ### Most common organisms that cause infective endocarditis: - **Most common organism** overall is St. viridans. - **Most common organism** in acute IE, in IV drug abusers, and Rt. Sided IE (I.e. Tricuspid valve IE): is S. aureus. - **Most common organism** after colonic resection is Bacteroides. - **Most common organism** in pts with colorectal Cancer is St. bovis. - **In pt. with prosthetic valve:** - Early post-op (2 months or less); the most common cause is Staph. Epidermidis. - Late (more than 2 months); like other population (ie. St. Viridans). ### Diagnosis of IE: - Clinically: Fever + murmur + spleenomagaly - Lab.: Diagnosis is by DUKE's criteria: you should have ALL Major criteria, OR ALL Minor criteria, OR 1 Major criterion + 3 Minor criteria. | Major Criteria | Minor Criteria | |---|---| | Immunologic phenomena: Glomerulonephritis: due to immuno-complex deposition -splinter hemorrhage. -Osler nodes: it is PAINFULL Nodules at the tips of fingers). -Roth spots: it is retinal hemorrhage. Vascular (Embolic) phenomena Janway Lesions: it is PAINLESS Nodules at the palm of the hand). Infarction in any organ: due to embolism caused by the vegetations, e.g. kidney or spleen infarction. | -Fever < 38 C -Risk factor: e.g. IV drug abuse, CHD, immunocompromised -Immunologic OR Vascular (embolic) phenomena -Atypical echocardiography findings -Atypical culture findings. | ### Note: - There are two types of Echo; transthoracic and transeosophageal. - Transeophageal Echo is better in IE because transthoracic Echo can't see vegetations < 2 mm ### IV vancomycin gentamicin (add rifampicin in prosthetic) ### Poor Prognostic features: - S. aureus: acute IE. - Fungal IE - Prosthetic Valve. - Low complement indicates heavy bacteremia (i.e. large number of bacteria that consume complement) # Valvular Heart Diseases ## 1. MITRAL STENOSIS ### Causes: - Almost always due to rheumatic heart disease. ### Symptoms: - S of pulmonary congestion: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough with frothy sputum, hemoptysis. - Pressure symptoms: because the Lt atrium is the most posterior chamber, it may compress recurrent laryngeal nerve (causing hoarseness of voice, called Ortner's syndrome), or it may compress esophagus (causing dysphagia). ### Signs: - pulse: Normal, AF pulse becomes irregular irregular. - Murmur: rumbling mid diastolic murmur. ### Complications: - AF - Embolization ### Investigations: - ECG: AF, P mitral (P wave bifid (M), due to left atrial dilatation), and P pulmonale (indicates Rt atrial dilatation). - Chest X-ray - Echocardiography: is the DIAGNOSTIC test. ### Management: 3 options - Closed/percutaneous balloon valvuloplasty - Open valvotomy - Valve replacement ## 2. Mitral Regurgitation: ### Causes: - divided into acute and chronic: - **Acute causes of regurgitation:** - Infective endocarditis - IHD - **Chronic causes of regurgitation:** - Connective tissue diseases: e.g. Marfan syndrome - Functional regurgitation: occurs in cardiomyopathies (DCM) ### Symptoms: - Congestion of the lung causes dyspnea, orthopnea, paroxysmal nocturnal dyspnea. - If Lt ventricle gets dilated it becomes non effective and pt develops heart failure (e.g. Low COP, fatigue). - Murmur: pan systolic murmur in apex radiates toward the axilla. ### Investigations: - Echo is diagnostic - In ECG - X-ray: Lt atrial and ventricular enlargement. ### Management: - Open repair. - Valve replacement. ## 3. Mitral Valve prolapse (MVP): - The most common valvular abnormality. ### Causes: - congenital (Connective tissue diseases e.g. Marfan and Ostoegenesis Imperfecta), or acquired. ### Symptoms: - Mostly asymptomatic. - Symptoms: atypical chest pain and palpitlition. ### Signs: - MVP produces mid systolic click, with progression of the disease it causes late systolic murmur. ### Complications: - Mitral regurgitation. - Embolization: e.g. stroke. - Arrhythmia (palpitation). - Sudden cardiac death. ### Management: - B blockers, or surgery" valve repair. ## 4. Aortic stenosis (AS): ### Causes: - are classified according to site of stenosis as either supra-valvular, valvular or sub-valvular: - **Supra-valvular:** William syndrome (associated with transient hypercalcemia, mental retardation and characteristic faces "elfin face" in addition to supravalvular AS). - **Valvular:** According to age of the pt: - Young pt > rheumatic heart disease. - Early adults (<65 yrs) > bicuspid aortic valve calcification. - Elderly (> 65 yrs) > senile calcification of normal aortic valve. - **Sub-valvular:** Hypertrophic Obstructive Cardio Myopathy (HOCM). ### Symptoms of Aortic stenosis: - triad of.. - Angina (chest pain). - Syncope on exertion. - Dyspnea. ### Note: - The most serious symptom of AS is Dyspnea because it occurs in advanced cases. ### Signs of aortic stenosis: - Pulse: Narrow pulse pressure. - Murmur: Ejection (mid) systolic murmur at aortic area 1, radiating towards the carotid. ### Investigations: - ECG - Echocardiography. ### Management: - If asymptomatic: No need for treatment, only follow up. - **indications of surgery:** Symptomatic: any of the above symptoms or if ejection fraction becomes less than 50% even if pt is asymptomatic. - **Type of Surgery:** Valve replacement or repair,

Pericardial Diseases PDF

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue