Myocardial and Pericardial Disease: Difference between revisions

Myocardial and Pericardial Disease (view source)

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 ==== Chronic constrictive pericarditis ====
 Any form of pericarditis may end in constrictive pericarditis, presenting with chronic fatigue, dyspnoea, jugular distension, proto-diastolic pericardial knock, hepatomegaly, ascites, peripheral oedema, and pleural effusion. Atrial fibrillation is a common finding, and diffuse flattened or negative T-waves are usually present. These suggestive clinical findings, in addition to a physiology of restriction or constriction on echocardiography, and the presence of a thickened pericardium provide the diagnosis. However, a thickened pericardium may be absent, which does not rule out constrictive pericarditis. Pericardiectomy is the only effective treatment, which should be instituted shortly after diagnosis, as surgical mortality increases with increasing age and functional impairment.
+==== Subacute elastic constriction ====
+Elastic cardiac constriction, in contrast to the rigid chronic constriction, results from an elastic thickened pericardium, which still allows distension during the respiratory cycle. It may be seen in the first period after acute inflammatory or infectious pericarditis, and may progress to chronic pericardial constriction, or prove to be a transient process.
+==== Effusive-constrictive pericarditis ====
+Mimicking cardiac tamponade on admission, effusive-constrictive pericarditis is characterized by a persistent increase in right atrial and end-diastolic ventricular pressures after intrapericardial pressure has been alleviated by pericardiocentesis. Apart from idiopathic cases, it may accompany chest radiation, cardiac surgery, neoplasia, and tuberculosis. Most frequently, the disease will progress to persistent constriction for which epicardiectomy is indicated, but it may rarely be a transient phenomenon.
+==== Transient cardiac constriction ====
+Clinical and hemodynamic features of constrictive pericarditis may dissipate spontaneously, which is seen commonly (20%) in idiopathic acute pericarditis with effusion, but may also be seen in tuberculous and purulent pericarditis. Hence, a primarily conservative approach may alleviate the need for epicardiectomy.
+=== Specific types of pericardial disease ===
+==== Infectious pericarditis ====
+===== Idiopathic/Viral pericarditis =====
+This is the most frequent form of pericarditis, accounting for more than 80% of cases, of which most probably are of viral etiology, but virus identification is cumbersome and no treatment consequences exist. The disease is frequently accompanied by pericardial effusion, cardiac tamponade, and left pleural effusion, but prognosis is notably good.
+===== Tuberculous pericarditis =====
+Predominantly found in developing countries, and patients with human immunodeficiency virus (HIV), tuberculous pericarditis is rare in the Western world, and presents typically with symptoms of acute pericarditis. Identification of Mycobacterium tuberculosis yields the diagnosis, which may be found in pericardial or other bodily fluids, or may be assumed when caseating granulomas are found. Routine tuberculosis treatment, comprising three antituberculous agents, yields a good prognosis although a subacute constrictive pericarditis is common, requiring pericardiectomy with excellent outcome.
+===== Purulent pericarditis =====
+Purulent pericarditis has a high mortality, owing to the intangible diagnosis and the related severity of the underlying disease. Cardiac tamponade is frequent, and acute constrictive pericarditis may occur. The disease should be considered in all patients presenting with high fever, dyspnoea, and tachycardia with intrathoracic or subphrenic infections, or sepsis with symptoms that suggest pericardial involvement. Pericardiocentesis is indicated even in the absence of tamponade when the disease is confirmed, and appropriate antibiotic treatment should be instituted. Long-term prognosis is however excellent in patients that survive until discharge.
+===== Post myocardial infarction pericarditis =====
+Pericardial effusion frequently occurs in the early stage after myocardial infarction, which remains asymptomatic and can be left untreated. Within the first week after myocardial infarction, acute pericarditis may occur, which is related to the extent of the infarction. The presence of a pericardial rub may distinguish chest pain and ECG changes resulting from acute pericarditis from recurrent ischemia.
+Weeks to months after myocardial infarction, pleuropericarditis of autoimmune nature may prevail, termed Dressler’s syndrome. The disease is now rare, and treatment with corticosteroids yields a good prognosis.
+===== Neoplastic pericarditis =====
+Lung cancer is the most frequent cause of neoplastic pericarditis. Cardiac tamponade in patients with a history of malignancy, in the absence of inflammatory signs indicates a possible malignant etiology, as is lack of response to NSAIDs in this patient group. When the effusion is indeed of malignant origin (approximately 40% of cases), treatment aims at alleviation of symptoms and the prevention of recurrences for which a balance should be sought between pericardiocentisis in which recurrence is frequent, and pericardiectomy, which may be overly aggressive in this critically ill subset of patients.
+===== Hypothyroidism =====
+With increasing severity of primary hypothyroidism, the prevalence of pericardial effusion increases. Thyroid hormone replacement therapy results in remission of the effusion.
+===== Post-pericardiotomy pericarditis =====
+Pericarditis is common after cardiac surgery (18%), of which the etiology is unclear although an autoimmune origin has been proposed. In contrast to other forms of pericarditis, post-pericardiotomy pericarditis may be effectively treated with corticosteroids and NSAIDs.