Pericardial disease March 2018 | by EMauthor Pericarditis •Etiology oViral: coxsackie B, echovirus, EBV, VZV, HIV oBacterial (from endocarditis, pneumonia, or prev cardiac surgery): S pneumococcus, s aureus oTB oNon-infectious oEffusion without pericarditis: CHF, cirrhosis, nephritic syndrome •Clinical Manifestations oChest pain: Pleuritic, positional (lessened by sitting forward), radiates to trapezius oFever oPericardial rub oDistant heart sounds if effusion oEwart’s sign: dullness over left posterior lung field due to compressive atelectasis •Ix oECG: PR depression and ST elevation followed later by T wave changes oCXR if effusion oEcho if effusion oPericardiocentresis •Treatment oNSAIDs or colchicine oAdmit if unwell, unable to rule out significant effusion Tamponade •Etiology: any cause of pericarditis but especially malignancy, uremia, proximal aortic dissection with rupture, myocardial rupture, idiopathic •Pathophysiology o↑ intrapericardial pressure, compresses heart throughout cardiac cycle oNarrow pulse pressure, so when tricuspid valve opens, pressure in RA = RV hence blunted y descent in JVP oPulsus paradoxicus •Clinical oDyspnea, fatigue oBeck’s triad: distant heart sounds, ↑ JVP, hypotension oNarrow pulse pressure, so when tricuspid valve opens, pressure in RA = RV hence blunted y descent in JVP oPulsus paradoxicus oDistant heart sounds, sometimes with rub •Ix oECG low voltage electrical alternans (ie weak trace, not every contraction present) oEcho: effusion, septal shift with inspiration, RA and RV diastolic collapse, respiratory alternations •Rx oVolume resus oDo not diurese oPericardiocentresis Constrictive pericarditis •Etiology: any cause of pericarditis but especially post-viral, radiation, uremia, TB, post surgery and idiopathic •Pathophysiology: rigid pericardium only limits the end part of diastolic filling hence ↑ systemic venous pressure and rapid early filling. Causes prominent x and y decents •Kussmaul’s sign: inspiration → increased venous return (normal) is not transmitted to heart due to rigid pericardium hence ↑ JVP •Ix oCXR: calcification in lateral view oEcho: thickened pericardium, rapid filling causing ‘septal bouncing’ Myocarditis •Etiology: usually viral, Coxsackie B and adenovirus, Chagas disease. Also idiopathic •Clinical manifestations ochest pain ofever opalpitations otiredness oshortness of breath oT wave inversion •Rx= symptomatic
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