Pericarditis is a pathological inflammatory process in the pericardial bag with a predominant damage to the visceral pericardial leaf, manifested by fibrosis (replacement of tissues by connective tissue) or by accumulation of fluid in the pericardium. These changes significantly reduce the physiological function of the heart muscle.
Pericardium is responsible for the correct position of the heart relative to other organs in the mediastinum. It consists of two layers: external fibrous and internal serous. The serous part is in turn divided into a serous sac and an epicardium. The latter tightly covers the myocardium. Between the epicardium and the heart muscle there is a small amount of CSF needed to reduce friction during contractions of the muscle.
In physically healthy people, the volume and composition of the pericardial cerebrospinal fluid is always the same, but with the development of pericarditis, the amount of fluid begins to grow, and the quantitative content of proteins increases substantially. These processes lead to compression of the heart muscle and prevent normal volumes of contractions, and later spikes begin to form.
Pericarditis can begin due to infectious respiratory diseases, chronic heart ischemia, autoimmune diseases, collagenoses, growth of tumor formations and allergies.
Pericarditis of the heart can be contagious and aseptic. In most reported cases, pericarditis develops against pulmonary tuberculosis and rheumatism.
Pericarditis in rheumatism has its own peculiarities: not only the pericardium, but also the endocardium and the heart muscle are involved in the pathological process. Pericarditis and rheumatic, and tubercular nature - is the result of an infectious-allergic process in the body. Tubercular damage to the pericardium occurs when the infectious agent enters the pericardial bag through the lymphatic vessels from the affected lung tissue and lymph nodes.
The risk of pericarditis increases significantly with such diseases as influenza , scarlet fever, tonsillitis and measles . To contribute to the development of this condition can and sepsis, as well as fungal and parasitic infestations.
In some cases, pericarditis can cause pneumonia, inflammatory processes in the pleura and endocarditis . In these cases, the infectious agent is transferred to the heart through the blood or lymphatic vessels of the chest.
Sometimes pericarditis can be a consequence of a heart attack, endo- or myocarditis. Non-infective pericarditis can develop in the postoperative period, with heart injuries (puncture wounds, severe bruises). To inflammation of the pericardium and the accumulation of pathological fluid can lead to cancer, gout and toxins of the body, for example, with uremia. Pericarditis can also develop in the pericardium with congenital defects (various cysts and protrusions of the wall), as well as in people with impaired blood circulation and edema of different genesis.
There are primary (arising as an independent disease) and secondary (as a consequence of already existing diseases) inflammation of the pericardium.
Pericarditis can be local, partial and diffuse. With the flow, acute and chronic forms of this pathological process are distinguished. Processes with acute pericarditis develop rapidly, the total duration of the disease does not exceed 5-6 weeks.
Exudative and dry pericarditis are distinguished. When dry in the serous membrane, a large amount of blood enters the vessels, therefore fibrin seeps into the pericardial cavity. With effusion of pericardial fluid in large quantities collected between the outer and inner leaves of the pericardium. Exudate with this form of pericarditis can be of various types: bloody, serous, serous-fibrinous and putrefactive.
Chronic inflammation of the pericardium lasts more than half a year, progresses slowly. There is a caked, adhesive and exudative-adhesive chronic pericarditis. Chronic exudate pericarditis develops in the same way as acute pericarditis, only the process takes longer. Adhesive, or adhesive, pericarditis is a residual phenomenon after other inflammations of the pericardial sac, characterized by an obvious adhesive process. The last type of chronic inflammation of the pericardium collects the symptoms of the two previous ones.
The manifestations of pericarditis directly depend on the type of process, its duration and the type of exudate. Pathology in most cases occurs against the background of an already existing disease, so there may not be a specific clinic.
Often patients with pericarditis note pain in their chests of varying strength, difficulty in breathing, especially after exercise, frequent heartbeats, arrhythmic accelerated pulse, dry cough, high fever, deterioration in general condition, noise produced by pericardial movement.
The person making such complaints is subjected to an in-depth examination. It includes a full examination, echo- and electrocardiography, X-ray of mediastinal organs, clinical analyzes. Upon examination, the swollen veins of the neck, the cyanotic skin tone, especially at the fingertips, near the lips and nose, swelling of the legs will be well visualized. When you study with a phonendoscope, you will hear a noise of friction. On the ECG the doctor will see a shift up the ST segment, and echocardiography will indicate the presence of fluid between the sheets. The blood will accelerate ESR, high C-reactive protein, leukocytosis, increased lactate dehydrogenase. A blood test can help detect markers that are characteristic of myocardial pathology: the level of troponin and creatine phosphokinase. X-ray is informative if there are serious irregularities in the configuration of the heart.
Pericarditis with signs of increased exudation often takes place after the transferred inflammatory diseases or allergic reactions. It is a complication of such serious diseases as tuberculosis and rheumatism, strepto- and staphylococcal infections.
The main sign of exudative pericarditis is the accumulation of fluid (exudate or transudate) between the pericardial sheets. Gradually, the parietal leaf begins to thin and deform. The first time hemodynamics does not suffer because of the increased pressure in the veins, as this contributes to the normal filling of the heart with blood. As the fluid expands, the pressure on the heart muscle increases, it begins to contract, causing a physiologically normal act of cardiac contractions to be disrupted.
The manifestations of exudative pericarditis depend on the nature of the accumulated fluid, the severity of the course, the amount of exudate and the rate of its stay. Because the heart muscle is difficult to expand on the diastole, the sick person complains of a weak pulse, pronounced cyanotic skin, a general weakness that can lead to a short-term loss of consciousness.
To make the correct diagnosis, you need to perform palpation and percussion of the chest. On an x-ray image, an increase in the heart will be seen only if the cavity contains more than two hundred milliliters of fluid. In this case, the outlines of the heart will be smoothed out, and the boundaries will increase both to the right and to the left. Echocardiography has an advantage over the X-ray, because it allows to detect the liquid in small volumes (from 50 milliliters). Echocardiography will also show hyperkinesia of the heart contour and the septum located between the two ventricles, as well as valve defects.
The signs testifying to the stretching of the cardiac fluid include: smoothing the gaps between the ribs in the affected area due to hypotension of the muscles, edema of the heart tissues, lagging in the respiration of the affected half of the thorax and protrusion of the epigastrium due to the displacement of the diaphragmatic muscle downwards.
The apex of the heart with exudative pericarditis rises to one or two intercostal spaces and shifts to the left. The veins on the neck do not pulsate, swell and become full-blooded. The boundaries of cardiac dullness, defined percutaneously, are significantly expanded, the heart is enlarged in the horizontal plane, the upper part of the abdominal wall does not participate in the act of breathing.
Voice tremor with exudative pericarditis is increased, breathing becomes bronchial from the angle of the scapula downward. In the knee-elbow pose, breathing is restored, crepitation and wheezing, small-bubble in nature, are heard. When listening to the heart, the tones are muffled, noise is heard on the systole.
Traumatic pericarditis is an inflammatory pathological process of the pericardium sac, resulting from various injuries of the chest.
The cause of traumatic pericarditis can serve as a penetrating wound of the mediastinal organs with a sharp object, bullet or fragmentation wound. Often, traumatic pericarditis develops due to a perforated ulcer of the stomach or esophagus.
Blunt trauma can also cause the development of this disease. Such damage a person can get in a car accident, in the collapse of buildings and a prolonged stay under the weight of debris, with improperly performed indirect massage of the heart, as well as in a fight.
Pericardium can be damaged in surgical infestations (rhythm driver installation, coronary angioplasty, catheter placement in the heart cavity for diagnostic purposes).
Traumatic pericarditis can be caused by a foreign body - the instrumentation or operating material forgotten in the pericardial cavity. Inflammation of the pericardial sac arises in some cases and after pericardotomy.
Traumatic pericarditis is often exudative and develops sharply, but in some cases, in the absence of examination and the necessary treatment can go into pericarditis chronic.
The first symptom of acute pericarditis is pain in the heart of a variety of expression and character. In most cases, the epicenter of pain is in the area of the xiphoid process or at the apex of the heart. Pain can spread to the left scapula and arm, neck, epigastrium. It can be sharp, intense and sharp, sometimes aching and drawing. Such feelings are a sure sign that pericarditis is dry.
The presence of ex- or transudate is characterized by the appearance of dyspnea, a sense of lack of oxygen. These symptoms increase depending on the amount of fluid and the rate of increase in volume. In the sitting position, breathing becomes much easier for the patient, since the fluid flows into the lower parts and the blood flow to the myocardium increases. A person tries to alleviate the condition by tilting the trunk forward.
Due to the fact that the pathological fluid presses on the bronchi and trachea and irritates the nerves, the patient begins a dry, debilitating cough. Vomiting may occur due to irritation of the branches of the vagus nerve. If the accumulation of fluid occurs in large quantities, bronchial breathing begins to be heard at the angle of the scapula.
Fibrinous pericarditis proceeds without changing the boundaries of the heart.
Exudative pericarditis is characterized by a decrease in the strength of the apical impulse, until its complete disappearance. Large veins of the neck increase, but pulsation with the naked eye is not visible. Of great importance for diagnosticians is the widening of the boundaries of cardiac dullness (both absolute and relative).
With dry pericardial during listening, the tones do not change or become slightly muffled, and with acute effusions they are strongly muffled, there is a tachycardia. For dry pericarditis, as well as exudate with a small amount of pathological fluid, a characteristic feature is the sound of friction of the pericardium. If there is a suspicion of acute dry pericarditis, and the noise is not audible in the vertical or horizontal position of the person, you should ask him to stand in the knee-elbow position or, if it is difficult to do, bend forward as much as possible. In this position, the sound of friction of the pericardium will be clearly audible. It is easy to distinguish from other sounds, since only it has a scratching character. This noise is best heard by inhaling air. With the accumulation of effusion, the characteristics of the pulse also undergo changes: the pulse amplitude becomes smaller, especially when inhaled. Thanks to this phenomenon, the symptom was called a "paradoxical pulse". In addition to all of the above, the patient has persistent hypotension .
If suspected of acute pericarditis, it is necessary to exclude myocardial infarction , cardialgia of various genesis and inflammation of the pleura. It is important to remember that pericarditis can become a complication of a heart attack. In this case, it is necessary to make the patient an ECG, check the level of alanylaminotransferases, asparagine aminotransferases, creatine phosphokinase and lactate dehydrogenase. A high-quality X-ray photograph will allow to determine the presence or absence of damage to the pleura and lung. The subjective sensations of the patient with the defeat of these organs and tissues are similar to the pericarditis clinic.
If acute dry pericarditis is an independent nosology, then it ends favorably under condition of adequate medical treatment and will not entail any consequences. Exemplary pericarditis much more often dry passes into a protracted current. Its danger lies in the fact that for a very long time it can develop without any manifestation of itself, and at that time a large number of adhesions are formed in the heart.
Careful attention should be paid to nonspecific benign pericarditis, which occurs mainly in young people after acute respiratory illnesses or severe hypothermia. Nosology in this case has an acute course, it develops very quickly, during 1-3 days, it is characterized by pain in the chest, in the projection of the heart, temperature rise to subfebrile condition and febrility. In the blood there is a large number of neutrophilic leukocytes, a significantly increased rate of erythrocyte sedimentation, a large amount of C-protein, DFA. When listening to a phonendoscope, the noise of friction is noted up to 4-5 weeks. Every fourth case of this nosology is capable of recurrence. Often the duration of the disease does not exceed one and a half months and does not entail any complications and residual effects.
More recently, pericarditis, associated with pneumonia, has become more common. They are of an infectious nature, against the background of pneumonia it is erased and very difficult to diagnose. Pain in this case is weak or nonexistent, the pericardial friction is heard in extremely rare cases. The amount of fluid in this disease is meager, so X-ray diagnosis is not informative.
This pericarditis threatens the patient with a transition to the adhesive, in which a large number of adhesions develop over the entire surface of the heart. With seeding of the pericardium with pyogenic cocci, a transition to purulent pericarditis is possible. It flows extremely hard. Characterized by high temperature, the phenomena associated with poisoning the body with endotoxins, increases the likelihood of tamponade. In the case of such a pericarditis, timely diagnosis is extremely important, since only a surgical operation can help a patient.
Constrictive (pericarditis) is a rare, but dangerous consequence of chronic forms of pericarditis. It leads to squeezing the heart muscle and decreasing its filling with blood. This disease is characterized by thickening of both the external and internal pericardial leaf, calcification and obliteration of the pericardium. All this leads to a deterioration of the blood filling on the diastole.
Constrictive pericarditis causes such diseases as purulent and tuberculous pericarditis, traumatic and postoperative pericarditis, inflammation of the cardiac bag in rheumatic diseases, after radiation exposure to the mediastinal organs, pericarditis uremic and acute viral. It can also develop as a complication of hemodialysis.
In the vast majority of cases, constrictive pericarditis is a complication of one of the exudative pericarditis. Normally, exudate pericarditis results in a complete resolution of the pathological fluid. But sometimes it happens that resorption for some reason does not happen. This leads to the formation of fibrinous fusion and, in the absence of the necessary treatment, complete obliteration of the cavities occurs. The result is the formation of gross scars on the entire surface of the heart, which prevent normal cardiac contractions and filling the chambers with blood. Violation of the physiological diastole leads to a decrease in stroke volume and pressure, a violation of filling the blood of organs located on the periphery.
Typical complaints with constrictive pericarditis are the formation of Beck's triad: abnormally high vein pressure, ascites, a diminished heart with subdued tones. An expanded clinic can manifest as a month from the beginning, and in a few years. The first signs appear that are characteristic for reducing cardiac output of blood: apathy, weakness, lethargy, frequent heart beat. First, such symptoms occur only when the body is stressed, and later appear at rest.
In a short time, shortness of breath is added to the above symptoms. First, it manifests itself under physical stress, and then - at rest. The reason for shortness of breath is not stagnation, but a decrease in the amount of blood in the pulmonary artery, leading to a disruption of the gas balance. A characteristic difference from heart failure is that in the prone position, dyspnea does not increase and orthopnea is absent. Lung edema and cardiac asthma also do not develop. In the great circle of blood circulation, the phenomena of stagnation begin. This is accompanied by an increase in the stomach and liver. Because of interruptions in the liver, patients rapidly lose weight, develop aversion to food, swelling of the legs.
When you look at yourself draws a very enlarged neck, the swelling also extends to the head and shoulders. This phenomenon is called in medicine Stokes collar, which speaks of a violation of hemodynamics of the superior vena cava and is a sign not only of the compressive pericarditis, but also of the cancer of the mediastinum.
Patients are trying to be in a reclining position, without pillows and headrests. With palpation of the liver, there is a significant increase in its left half, painful pressure, the organ is dense. Despite the fact that hemodynamic disorders are very pronounced, stagnation in the lungs is not detected.
When examining vessels, it can be noted swelling of the veins on the neck, which can not be removed even with strong diuretic drugs. The protrusion of the veins is particularly evident when the patient breathes in. The apical impulse and pulsating waves in the epigastric region can not be detected. A deep breath can be accompanied by retraction of intercostal spaces. This sign indicates the development of adhesions between the pericardium and the chest wall.
An important diagnostic feature is that when a person turns to the right side, the boundaries of the heart are not shifted at all, since by means of the scar the heart is firmly fused to the front wall. When auscultation can hear the rhythm of the gallop, due to the emergence of an additional third tone. The third tone - pericardial tone, differs in its intensity.
The prognosis of constrictive pericarditis mainly depends on the nature of the course of the main disease. The term of life without treatment by surgery is no more than ten years, but with adequate treatment, the prognosis and quality of life improves.
The treatment scheme directly depends on the type of pericarditis and the severity of the course of nosology. In acute form, hospitalization in the hospital is necessary, pericarditis with mild manifestations can be treated and outpatient.
For the therapy of pericarditis, non-steroidal anti-inflammatory drugs are used. Ibuprofen has proved itself well. It has a minimum number of side effects and good tolerability. The dosage of this remedy depends on the shape and severity of the pericarditis and varies between 400-800 milligrams per dose. Take it three times a day after eating. Children are dosed at the rate of thirty milligrams per kilogram of body weight. If the liver is involved in the pathological process or the patient has diseased kidneys, the medicine should be prescribed with particular caution.
If the patient suffers from ischemic heart disease, Ibuprofen should be replaced with Aspirin or Diclofenac.
A mild form of pericarditis is treated by prescribing Diclofenac in the form of tablets. This drug is taken twenty-five to fifty milligrams every eight to twelve hours. Acute forms of pericarditis with a deployed clinic are treated with an injectable form of the drug. Assign injections of Diclofenac at a dose of seventy-five milligrams per injection. The injections are done in the gluteus muscle two or three times a day. If the patient has a stomach ulcer in the period of exacerbation, this drug can not be prescribed.
Aspirin is prescribed five hundred to thousand milligrams two or four times a day. It is necessary to appoint it with extreme caution to people who have stomach and intestinal diseases, since this drug stimulates the development of ulcers.
NSAIDs prescribe under the cover of drugs that protect the stomach from their harmful effects on the mucous membrane (De-Nol, Almagel). De-Nol drink one or two tablets before eating twice a day. Almagel take two measuring spoons twenty minutes before eating. The duration of administration of these funds is equal to the duration of therapy with nonsteroidal anti-inflammatory drugs.
If the use of a patient with Ibuprofen, Aspirin and Diclofenac is not possible, Indomethacin is prescribed. For the treatment of acute pericarditis Indomethacin is pricked into the muscle. The dose for one administration is sixty milligrams of medication. Enter the drug once or twice a day, the duration of admission should not exceed two weeks. This drug is prohibited for use in patients suffering from any ulcerative processes, as well as bronchial asthma , since conditions that threaten life can develop.
Correctness of the prescribed treatment of pericarditis is evaluated after two weeks. If the therapy gives good results, the dose of the drug is halved and the treatment continues for another seven days.
Along with NSAIDs, antibiotics are prescribed. Penicillin is prescribed for nonspecific pericarditis of infectious genesis. Often, the drugs of choice are Ampicillin and Amoxicillin. The dose of Ampicillin for one dose is 500 milligrams, the number of receptions per day is three to four. This drug can be taken regardless of the diet. The drug is prohibited for use in people with allergic reactions to penicillins. Amoxicillin is prescribed in a daily dose of one and a half grams, divided into three doses. With a severe complication of pericarditis, the dose of the drug can be increased to three grams per day.
With pericarditis caused by tuberculosis of the lungs, Streptomycin is used. The required daily dose of Streptomycin is one gram. Patients with tuberculosis it is administered intramuscularly once. If undesirable effects occur, the daily dose can be administered in two steps.
Pericarditis caused by systemic lupus erythematosus or rheumatoid arthritis is treated with glucocorticoids. Well-proven synthetic analogue called Prednisolone. It is usually prescribed in small doses (ten to fifteen milligrams per day). In severe cases, the dose can be increased to thirty milligrams (six tablets).
Treatment of constrictive pericarditis is a surgical operation to remove both pericardial sheets, since the therapy with drugs here will not have any effect.
Tamponade of the heart is often also treated by surgeons, but in some cases, medication is possible with diuretics. In this case, the main goal is complete cure of the primary disease.