Acute pericarditis

Acute pericarditis . It consists of acute inflammation of the pericardium in response to various agents (viral, systemic diseases , malignancies , radiation, medications, etc.), and which can progress to effusion and then to constriction, or one of these.

Summary

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  • 1 Diagnosis
  • 2 Causal classification of pericardial disease
  • 3 Treatment
  • 4 Complementary exams
    • 1 Laboratory tests
    • 2 Other exams
    • 3 Forecast
  • 5 Cardiac tamponade
    • 1 General treatment
  • 6 Sources

Diagnosis

  1. Pain. 2. Fever. 3. Pericardial rubbing. 4. EKG changes. 5. Spill that can be made recurrent. 6. May be accompanied by pericardial effusion.

The main symptom is chest pain, it is usually precordial, but it can change more to the left side and simulate pleurisy; It is relieved by standing up and increases with inspiration. On physical examination, it is characteristic to find pericardial rubbing (pathognomonic sign), it is usually superficial and raspy, it can be widely distributed in the precordium, but it is usually more noticeable in the external left border. It is best appreciated by pressing the diaphragm of the stethoscope.

Causal classification of pericardial disease

  1. Idiopathic and nonspecific acute.
    2. Acute myocardial infarction.
    3. Post-heart attack syndromeDressler’s syndrome).
    4. Penetrating or non-penetrating trauma.
    5. Post-thoracotomy syndrome or post-cardiotomy syndrome.
    6. Connective tissue diseases: rheumatoid arthritis, rheumatic fever, disseminated lupus erythematosus, scleroderma, and Takayasu arthritis.
    7. Specific infections: a) Bacterial infections (gonococcal and meningococcal disease).
    b) Tuberculosis. c) Fungal infections: histoplasmosis, nocardiosis and blastomycosis.
    d) Viral (coxsackie B virus, ECHO influenza).
    e) Amebiasis.
    f) Toxoplasmosis.
    8. Primary or metastatic neoplasm, which includes lymphomas and leukemias.
    9. Irradiation.
    10. Aortic aneurysm: rupture or leak of a dissecting aneurysm in the pericardial sac.
    11. Drugs: hydralazine, psychofuramine, procainamide, treatment with anticoagulants, nicotinic acid hydrazide and penicillin.
    12. Chilopericardium.
    13. Uremia and associated with hemodialysis.
    14. Various: sarcoidosis, myxedema, amyloidosis and multiple myeloma.

Treatment

Acute pericarditis can heal spontaneously.

It responds very well to non-steroidal anti-inflammatory drugs (indomethacin, 25-50 mg, 3-4 times / day, ibuprofen, and others).

Sometimes aspirin promotes satisfactory evolution.

Resistant cases require prednisone 75 mg, and it is rapidly decreased to minimal doses.

Complementary exams

Laboratory exams

  1. Blood count.
    2. Urea.
    3. Eritrosedimentation.

The results of these tests are altered according to the underlying disease (uremia, rheumatic fever, pyogenic infections, etc.).

Other exams

  1. Electrocardiogram:in the acute phase, the earliest sign is the appearance of high, pointed, symmetrical T waves, almost always associated with ST-segment elevation in most ECG leads. The ST segment is of superior concavity. The elevation difference is most visible in DII, V4 to V6. There may be displacement of the PR segment, which is secondary to inflammation of the pericardium. Sinus tachycardia is always present. In the evolutionary phase the ST segment is less concave, mainly because in this phase the T wave loses its amplitude and becomes isoelectric. ST also becomes isoelectric and the flat wave, diphasic or inverted, can remain so for weeks or months. It is also observed low voltage and sometimes electrical alternation that can occur in the pericardial effusion.

    2. Radiology:in pericarditis the cardiac figure may persist unchanged. In effusion pericarditis, the cardiac silhouette becomes uniform and acquires a triangular, pear-shaped configuration, in the form of water pockets or an inverted cup. The vascular pedicle widens.

    3. Echocardiogram:With the two-dimensional technique, the separation of the layers of the pericardium and especially the extent of the effusion are easier to demonstrate. Quantification of pericardial effusion has been attempted with the M technique, which, as is known, classifies the different images of the effusion in different patterns according to the degree of severity. When the effusion is significant, the heart has a very broad and sometimes alternating global movement. A series of signs have been described with the M technique for the diagnosis of cardiac tamponades, a decrease in the EF slope of the anterior mitral valve, an inspiratory increase in the diameter of the right ventricle (RV), and the existence of a notch at the level of the anterior wall of the RV (can also be seen with the two-dimensional technique).

    4. Pericardial puncture:it checks the diagnosis and allows the cytological, chemical and bacteriological analysis of the accumulated material; It also has a therapeutic objective. The spill almost always has physical characteristics of exudate. Bloody fluid is often seen in tuberculosis or tumor, it can also be found in rheumatic fever, in cardiac trauma, and especially after administration of anticoagulants.

Forecast

Most episodes resolve within 2 to 6 weeks. Complications may be cardiac tamponade (15%), constrictive pericarditis (10%), recurrent pain (25%), and arrhythmias.

Cardiac tamponade

The accumulation of fluid in the pericardial cavity in an amount such as to cause serious obstruction when blood enters the ventricles, causes cardiac tamponade. It is the most important complication of pericarditis, which in turn constitutes a medical emergency.

The clinical picture of cardiac tamponade is manifested by the Beck triad, which consists of elevated venous pressure, decreased arterial pressure, and a still heart; The latter is preferably observed by fluoroscopy.

Most often, cardiac tamponade develops slowly and the clinical manifestations then resemble those of heart failure such as dyspnea, orthopnea, hepatomegaly, and jugular venous hypertension and paradoxical pulse. From the hemodynamic point of view the following changes are observed:

  1. Progressive increase in venous pressure. 2. Decreased cardiac output per beat. 3. Increased heart rate. 4. Increased arm-lung circulation time. 5. Drop in blood pressure. 6. Decreased vital capacity.

General treatment

Hospitalization and bed rest, to observe the tamponade. If there is pain, aspirin 650 mg should be administered every 3 or 4 h; indomethacin 25-50 mg every 6 h. If meperidine is kept 25-50 mg by IM or EV routes every 3 or 4 h, morphine 2-15 mg by IM or EV routes every 4-6 h; if it persists 48-72 h, prednisone 60-80 mg / d in divided doses. In general, administering high doses of medications requires 5 to 7 days and other anti-inflammatory agents. Anticoagulation is not recommended in cases of cardiac tamponade. If there is a prosthetic valve, heparin is used via the EV route and protamine sulfate is used if a pericardial effusion occurs.

 

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