Pericardial Diseases PDF

# Pericardial Diseases ## 1. Acute pericarditis - **Causes:** - **Idiopathic** - **Infection**: viral (most common), fungal, bacterial (TB) - **Uremia**: uremic pericarditis in renal failure indicates need for dialysis - **Hypothyroidism** - **MI** - **Autoimmune arthritis...

# Pericardial Diseases ## 1. Acute pericarditis - **Causes:** - **Idiopathic** - **Infection**: viral (most common), fungal, bacterial (TB) - **Uremia**: uremic pericarditis in renal failure indicates need for dialysis - **Hypothyroidism** - **MI** - **Autoimmune arthritis and SLE** - **Clinical presentation:** - **Symptoms**: Pleuritic chest pain that is worse by lying flat and relieved by sitting forward. - **Signs**: Pericardial friction rubs - **Investigations:** - CBC, ESR - ECG: - Global concave (saddle shaped) ST segment elevation. - **Most specific ECG finding**: PR depression - **Management:** - **First line:** NSAID (Ibuprofen) + treatment of underlying cause. - **Second line:** Colchicine + treat underlying cause. (Colchicine prevents WBCs migration to site of inflammation). - **Steroids**: only given in severe cases because it decreases immunity. ### Note: Chest pain can be cardiac or pleuritic - **Cardiac chest pain:** 1. **Central, crushing, radiating to jaw or left arm** 2. **Increases** with exercise, heavy and fatty meals, stress, and cold 3. **Relieved** by rest or sublingual nitrates - **Pleuritic chest pain:** 1. **Sharp, localized pain** 2. **Aggravated** by deep inspiration and cough ### Differential Diagnosis of ST segment elevation: 1. **Pericarditis:** ST elevation is global (in all leads), and saddle (concave) shaped 2. **MI:** ST elevation is localized to certain leads, and it is convex in shape. ## 2. Pericardial effusion - **Causes:** Same as acute pericarditis - **Clinical features:** - **Ewart sign**: bronchial breathing in the base of left lung (because the pericardium contains fluids that compress the base of left lung). - **Diagnosis:** - **ECG**: 1. Low voltage QRS 2. Electrical Alternans (short QRS complex with an altered height, sometimes short, sometimes even shorter, due to the heart floating on water and having an instable, fluctuating position). - **CXR**: enlarged heart (cardiomegaly) - **Echo**: **Diagnostic test**, there is an echo-free zone around the heart. - **Treatment:** - By treating the underlying cause. - **Periocdiocentesis** may be used as diagnostic and therapeutic ## 3. Constrictive pericarditis - **Definition:** Stiffness of the wall of the pericardium that limits contractility of the heart. - **Clinical features**: Symptoms and signs of right sided HF. - **Note**: Constrictive pericarditis and restrictive cardiomyopathy have the same clinical presentation of right sided heart failure. - **Kussmaul's sign**: paradoxical rise of JVP with inspiration (normally JVP decreases with inspiration because the intrathoracic pressure becomes negative, causing venous return to increase and JVP to decrease. But in constrictive pericarditis stiffness prevents the increase of venous return.) - **Deep x and y descents in JVP** - **Investigations:** Imaging (CXR, CT, MRI) shows a calcified pericardium. - **Management:** Pericardiectomy. ## 4. Cardiac tamponade - **Causes:** 1. Aortic dissection 2. Trauma 3. Anticoagulants (Warfarin) 4. Post cardiac bicposy - **Clinical features**: - **Beck's triad:** 1. Raised JVP 2. Low BP 3. 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, causing blood to accumulate in the heart. But this drop in BP is never larger than 10 mmHg. (For example: if BP 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 have similar findings (both are due to fluid accumulation). - **Treatment**: Pericardiocentesis (drainage) + treatment of underlying cause. # Cardiomyopathies ## 1. Dilated cardiomyopathy (DCM) - **Definition:** Global enlargement and dilation 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**: mitral regurgitation - **Diagnosis:** By Echo: There is an enlarged heart. - **Complications:** 1. **Thrombosis and embolization:** due to stasis of blood that occurs due to weak contraction. 2. **Arrhythmia** when the dilatation of chambers involves the conductive system. - **Treatment:** - Treatement 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 right sided 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 the 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 right sided heart failure. - **There is diastolic failure** - **Diagnosis:** - **Myocardial biopsy** through cardiac catheterization. - **Cardiac transplantation.** - **Management** - **Prognosis**: 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 | Increase | Decrease | | Squatting | Decrease | Increase | | | murmur | murmur | - **Diagnosis:** By Echo: **Mnemonic**: MR SAM ASH - **Note**: The cause of death in patients with Friedrich's ataxia is HOCM. Duchenne causes DCM. - **Note**: Vasodilators are contra-indicated in obstructive lesions (HOCM and AS). ## Myocarditis - **Inflammation of the cardiac myocytes.** - **Causes:** - **Viral**: Coxsackie virus B, parvovirus B19, human herpesvirus-6, adenovirus, and HIV. - **Bacterial** : Diphtheria. - **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 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 as cardiac pain.** - **Causes of cardiac pain:** - **Decreased blood supply to the heart** - **Increased demands** - **Decreased oxygen carrying capacity of blood** - **ischemic heart diseases include:** 1. **Stable angina** 2. **Variant angina** 3. **Acute coronary syndrome (ACS)** - a. Unstable angina - b. Non-ST segment elevation myocardial infarction (NSTEMI) - c. ST-segment elevation myocardial infarction (STEMI) - d. Sudden cardiac death (SCD) ### Criteria of Cardiac Pain: 1. **Central, crushing, radiating to jaw or left arm** 2. **Aggravated** by exercise, stress, emotions, and cold. 3. **Relieved** by rest or sublingual nitrates. - **If all 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.** - **Patient 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 1. **Exercise Echo** 2. **Thallium scan** (also called myocardial perfusion scan): decrease perfusion 3. **Exercise ECG**: not diagnostic, just gives probability of having angina - **Patient with angina who does not have any history of CAD:** We should calculate cardiovascular risk as follows: - **Cardiovascular risk > 90%**: start treatment immediately. - **Cardiovascular risk 90-61%**: do angiography. - **Notes:** - **Male patient older than 70 years:** You should start treatment immediately. - **Female patient older than 70 years:** Do angiography. - **Cardiovascular risk 60-30%**: do functional studies. - **Cardiovascular risk 29-10%**: do calcium CT score. - **Cardiovascular risk < 10%**: consider another diagnosis. - **Management**: 1. **Life style modification**: Diet, exercise, quit bad habits, control risk factors (DM, HTN, hyperlipidemia). 2. **Symptomatic drugs (monotherapy):** - **Sublingual nitrate (GTN):** Sublingual at home or as a spray, given when symptoms occur or as prophylaxis. - **B blockers** - **Anti-platelet therapy**: e.g. aspirin (to decrease mortality) 3. **If not controlled** by monotherapy: - **Add calcium channel blockers (CCB)** - **The invasive procedures are:** - **PCI** - **Coronary Artery Bypass Grafting (CABG)** ## 2. Variant "Prinzmetal" Angina - **Caused by sudden spasm of coronary artery.** - **Clinically:** Patient 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 - **Cardio-selective (Verapamil and diltiazem):** they can be given alone for patients with angina. ## 3. Acute Coronary Syndrome (ACS) - **D.D. of ACS:** 1. **Unstable angina** 2. **Non-ST segment elevation myocardial infarction (NSTEMI)** 3. **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:** - **Unstable angina:** There is no ST elevation and no cardiac markers. - **NSTEMI:** There is no ST elevation but cardiac markers are elevated. - **STEMI**: There is ST elevation and cardiac markers are elevated. ## Myocardial Infarction (MI) - **Types of STEMI:** 1. **Anterior MI:** - **Blockage is in the left anterior descending artery** - **It is the most common type.** - **ECG changes:** ST elevation in chest leads from V1 to V4. 2. **Lateral MI:** - **Blockage is in the left circumflex artery.** - **ECG changes**: ST elevation in the lateral leads (V5, V6, aVL, and lead I). 3. **Inferior MI:** - **Blockage is in the right coronary artery.** - **ECG changes:** ST elevation in aVF, lead II, and lead III. - **Right coronary artery supplies conductive system of the heart (AV node and SA node), that is why patients with inferior MI present with heart failure with bradycardia.** 4. **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 and 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 the patient develops re-infarction, do CK-MB because troponin of the previous MI has not dropped yet.** - **Management of acute coronary syndrome:** 1. **Give MONA to all patients** (Morphine, O2, Nitrates, and Aspirin.) 2. **Then do serial ECG and serial cardiac markers, and then according to results:** - **A. If ST elevation (STEMI):** after giving MONA, do reperfusion therapy: 1. **PCI:** Always superior to thrombolytic therapy, the ideal time is 90 minutes. 2. **Thrombolytic therapy**: by streptokinase or by tissue plasminogen activator (tPA), the optimum time is 30 minutes. - **B. If there is no ST elevation: This is either NSTEMI or unstable angina, both of them have the same treatment:** After giving MONA, give heparin then assess the cardiovascular risk (according to GRACE score): - **If the patient has a high risk GRACE score**: give him glycoprotein IIB/IIIA inhibitor, and do angiography in 4 - **Note**: high risk GRACE score: - Diabetes. - ST depression. - Persistent or recurrent ischemia. - High cardiac markers. ## 3. Then give discharge medications. - **The first 4 drugs are similar in all types of ACS** 1. **Aspirin for life.** 2. **B blockers for life.** 3. **ACEI for life** 4. **Statin for life** 5. **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 1. **Cardiogenic shock:** Treated same as heart failure 2. **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 a pacemaker.** 3. **Pericarditis:** Two types: -