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Pericarditis

Pericarditis is essentially an inflammation of the pericardium, which is a fibrous sac that contains the heart. It can be due to various causes like infection or any trauma to the sac.This inflammation could lead to various kinds of problems .

Symptoms

Patients with pericarditis usually present with symptoms of chest pain that is acute onset, sharp, retrosternal, or along the left precordium.

 It’s pleuritic in nature, which means it varies with inspiration/expiration . And classically, it’s improved with change in posture like sitting up and leaning forward.  

Also, in some cases when the inflamed layers — so this includes the visceral and parietal pericardium– rub against one another, they can actually make noise, which we call a friction rub.

 This is an odd sound that is actually quite variable in presentation. Some describe it as scratchy or squeaky or even a high-pitched type sound. 

It can be mono, bi, or even tri-phasic, with each phase corresponding to phases of the cardiac cycle, which would be atrial systole, ventricular systole, and ventricular diastole. 

Friction rubs are best heard with end eend-expirationtening with the diaphragm of your stethoscope at the left lower sternal border.  

Diagnosis with an ECG

There are some classic ECG findings associated with the disease. The classic ECG changes are actually seen in about 60% of cases of acute pericarditis. They are:- 

  • When present, you’ll see diffuse, concave upward ST elevations. And by diffuse I mean that you can essentially see the ST elevations in any lead, with possibly the exceptions of aVR and sometimes V1, where you actually see reciprocal ST depressions instead.
  •  Also, a less sensitive but highly specific ECG sign of pericarditis is diffuse PR segment depression with corresponding PR segment elevation in aVR. Also, as a side note, typically you will not see these ECG changes in the setting of uremic pericarditis.  .
  • Diffuse ST-segment, most pronounced in lead two, aVF and ,then V2 through V6. Notice how there is even subtle ST depression in aVR as well. In precordial leads, you can see the ST elevation in V4 through V6.

Causes

One major cause of pericarditis is infectious disease. This could include :- 

  • Viral etiologies
  • HIV
  • Fungal
  • TB
  • Even bacterial infections can cause pericarditis.

 Pericarditis is also seen with inflammatory diseases, especially in autoimmune disease like :- 

  • Lupus, 
  • Rheumatoid arthritis, 
  • Scleroderma,  
  • Mediterranean fever.
  •  Also some primary cardiac diseases, including myocarditis which is inareammation of the myocardium.
  •  And also something called the post-cardiac injury syndrome that classically was called Dressler’s Syndrome, which is essentially pericarditis following either a large heart attack or following cardiac surgery.  
  • Also, you need to consider neoplastic causes, since metastatic lung and breast cancer and lymphoma have been known to cause pericarditis, usually associated with a pericardial effusion. 
  • Rarely, there are some metabolic diseases, like uremic pericarditis and hyperthyroidism, that have been described.
  •  Radiation has been described as a cause as well. But overall, about 80% of the reported cases that we see actually fall under the idiopathic category, since we cannot find any other explanation for the syndrome.  
  •  Sometimes myocarditis is also associated with pericarditis . And when this overlaps, you can actually call it as myopericarditis.  About 60% of patients with pericarditis will also have a pericardial effusion, so it is actually relatively common to find this. 

What makes pericarditis worse?

Pericarditis can be also be related with 

  • Cardiac tamponade
  • Signs of poor perfusion, hypertension
  • Tachycardia, 
  • An elevated pulsus paradoxus. 

Pericarditis can also be associated with bacterial or tubercular infection, malignancy, or autoimmune disorder, then the effusion will require drainage as part of your diagnostic workup. 

 Often constrictive pericarditis  is  another complication sometimes seen years after an episode of pericarditis. This is the development of a thickened fibrotic pericardium secondary to the prior inflammation.

 This thick sack now restricts cardiac filling.

It causes right heart failure symptoms, such as:-

  • Dyspnea
  • Elevated jugular venous pulse, 
  • Edema
  • Ascites. 

This typically occurs after an infectious or inflammatory pericarditis, or following cardiac surgery.  

Treatment

First, we’ll we will try to determine the cause and we’ll try to classify pericarditis, we will see these whether the presented cases of idiopathic/viral variety

Since this is the majority of cases that you’ll see.So:-  

  •  First-line therapy is anti-inflammatory therapy with either aspirin or a non-steroidal medicine
  • Second line therapy is used for refractory symptoms , it includes use of colchicine. And this can be used alone or in combination with aspirin or an NSAID. 
  • Glucocorticoids can be used, but it’s actually recommended to only use if their symptoms are refractory to the above therapy or if other agents are contraindicated. And if the patient is having recurrent pericarditis over time, a prolonged course of colchicine is the preferred therapy in this setting.  

Various types of pericarditis and its treatment

The treatment of pericarditis, based on some of the other etiologies, is actually specific to what underlying cause ., various kinds of pericarditis and its treatment is :-

Bacterial will require antibiotics and drainage. 

Neoplastic   will likely require chemotherapy plus or minus drainage for symptom relief and to establish the initial diagnosis.

Autoimmune In autoimmune pericarditis disease we typically use glucocorticoids as the initial agent. 

Uremic we would treat with hemodialysis and also glucocorticoids. 

Post-cardiac injury responds very well to colchicine. And we still recommend that you avoid anticoagulation, if possible, due to the possibility of the patient developing a hemopericardium.  

Also  invasive management of pericardial disease is needed in various cases. If there is an associative pericardial effusion that is hemodynamically significant and causing cardiac tamponade would you need to perform an urgent pericardiocentesis.

Rarely, if someone is having frequent, significant recurrence of acute pericarditis, the surgeons may consider a pericardiotomy. 

If constrictive pericarditis, which is causing significant morbidity to the patient, then a pericardiotomy or pericardial stripping procedure may be indicated. 

 In summary, pericarditis typically presents with acute onset, pleuritic chest pain, friction rub, and the characteristic ECG changes. 

There’s a wide differential, but most cases are actually idiopathic or viral and can be managed with anti-inflammatory medications. 

Associated effusions are common, but really only need to be drained if certain diagnoses are more likely or if there is hemodynamic compromise. 

Questions

Q) Is pericarditis serious ?

Ans: It is the inflammation of the sac that surrounds the heart ,it can be due to various causes like infection or disease. So if left untreated then it can lead to serious complications. The two major complications that are most common and most feared are cardiac tamponade and chronic constrictive pericarditis.

Q) What is the main cause of pericarditis ?

Ans:- It is caused by various causes like :- 

Fungal ,Bacterial or viral infection:- any kind of infection which causes inflammation of  the sac around the heart can lead to inflammation of heart sac..

Autoimmunity :- can also be the leading cause of pericarditis because due to autoimmunity the body immune system attacks the cells of the heart Sac which cause its inflammation.

High urea level in blood :- high concentration of urea in blood due to various physiological and pathological causes can also it did the lining of the heart check it into its inflammation.

Surgery :- surgery can also be one of the main factors which cause inflammation of the heart sac. Pericarditis is often seen after an open heart surgery or any cardiac surgery. Because in any kind of surgery of the heart sac , its a very high probability that it might get infected, leading towards inflammation.

Cancer:- any kind of neoplasia or tumor can also be a leading cause of inflammation of the heart sac. Though it is not very common,  it is seen in patients who are undergoing treatment of chemotherapy . 

Q) How long does pericarditis last ?

Ans:- It is classified into various types on the basis of the pattern of symptoms and the length of duration that it lasts.

 Symptoms of acute pericarditis easily subside in less than 3 weeks. But in incessant pericarditis the symptoms are at peak for about 4 to 6 week and usually subside within 3 months.

Q) what is the best treatment for pericarditis? 

Ans:- Treatment of inflamed pericardium includes treatment of the underlying cause along with painkiller medication.

 Antibiotics like streptomycin amoxicillin etc purple striped when there are chances of any infection. 

Painkiller medications like Aspirin brufen etc are prescribed to the patient to relieve the uncomfortable.

Q) Does pericarditis damage the heart? 

Ans:- In serious complications like cardiac tamponade and chronic constrictive pericarditis, can cause damage to the function of the heart. This can also prove fatal if left untreated.

Q) How does pericarditis feel ?

Ans:- In cases of acute pericarditis symptoms like , sharp pain( which is stabbing in nature) is felt around the heart, aur aur in the left region of the chest. The plane is also included with the shortness of breath and often worsen during breathing in air. It can also be associated with heart palpitations.

Q) Does pericarditis show on ECG ?

Ans:- An electrocardiogram ie.ECG test is very useful in determining any serious symptoms which can be related with pericarditis . Like in constrictive pericarditis any change in the normal rhythm of heart or stiffness or thickness of pericardium can be seen very clearly along with normal movements of heart.

Q) what is the prognosis of pericarditis?

Ans:- Usually the patients of acute idiopathic and viral pericarditis have a  history of very long-term prognosis. Patients with cardiac tamponade are usually present with acute idiopathic pericarditis and are also very common in underlying etiology like tuberculosis cancer or purulent pericarditis.

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