Pericarditis: description of the types, symptoms and treatment

Scientific editor: Strokina OA, therapist, doctor of functional diagnostics.
September 2019.

Pericarditis - an inflammatory disease of the pericardium (pericardium) to form a cavity in its effusion (Liquid) or without it. According to the character is divided into acute, finished the cure, recurrent and chronic. Also, experts are divided on the etiology of disease and inflammation of the form. In diagnostics importance occupy imaging techniques. Treatment is to limit physical activity, appointment of medication regimens, while their ineffective use of surgical intervention.

Pericardium is called the outer layer of the heart of the 2 sheets, containing the organ itself and the roots of the major blood vessels. Between the sheets is 10-15 ml pericardial fluid, which helps the heart to contract without much friction.

When inflammation of the pericardial cavity accumulate and eventually formed elements (liquid fibrin, pus, calcification, adhesions) that violate the main function of the heart to pump blood. Because of this, other organs begin to suffer, their failure develops.

Photo: Normal heart and heart with inflammation of the pericardium

Kinds

Pericarditis classified in many ways. The greatest value among them is the cause of. On this basis, and isolated infectious pericarditis neinfektsinnye.

infectious:

• viral pericarditis - the most frequent in occurrence, their causative agents include enteroviruses, herpes viruses, adenoviruses, parvovirus;
• parasitic and bacterial, such as tuberculous pericarditis (most common in developing countries - up to 60%), pneumococcal, meningococcal, gonococcal, streptococcal, staphylococcal, mycoplasmal and other;
• fungus - an extremely rare variant.

noncommunicable:

• autoimmune pericarditis develops more often in sistemnyo lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, scleroderma, systemic vasculitis, sarcoidosis, Still's disease;
• neoplastic, the most common cause - a malignant neoplasm of the lung, breast, lymphoma;
• metabolic, more common uremic pericarditis (impaired renal excretion products of protein metabolism) also develops in myxedema (extreme form of hypothyroidism - deficiency of thyroid hormones) anorexia;
• traumatic pericarditis, occurs due to damage the thorax, esophageal perforation, radiation (radiation pericarditis), percutaneous coronary intervention;
• officinalis, owing to prolonged use of different groups of drugs.

Often, the cause of inflammation of the pericardium is not known, this is called idiopathic pericarditis.

The correct formulation of the diagnosis there is another important classification of diseases - syndromic:

acute pericarditis

• Acute pericarditis is characterized by rapid development and takes no more than 1 week. As the substrate in the cavity is isolated fibrinous (dry) pericarditis, when many delayed fibrin (protein from composition of blood plasma) and a little liquid, pericarditis and exudative (or exudative) to form for the most part liquid.

subacute

• Subacute inflammation of the option proceeds are not as active, and lasts from 1 week to 3 months. secrete constrictive, Constrictive, exudative. Constriction is due to thickening of the pericardial leaflets, education calcifications and hard adhesions between them, which greatly reduces the possibility of normal movement of the heart inside the bag while it is reductions. At the same time most affected the function of the ventricles relax and fill with blood.

palindromic

• Recurrent pericarditis - a disease which is characterized by the return of clinical symptoms some time after discontinuation of treatment - intermittent option, and permanent, in the case of an immediate recovery of symptoms after discontinuation of drugs. Constriction, cardiac tamponade - a rare phenomenon in recurrent variant of the disease.

Chronic

• Chronic pericarditis - an inflammation of the pericardium lasting more than 3 months. Often, patients suffer for years or even for life. It manifests constrictive embodiment, in the form of effusion (pericardial effusion), also isolated by the adhesive or adhesive, wherein the pericardial leaflets are welded to each other, but softer structure than the constrictive version. Adhesive shape formed after radiation exposure. In addition there may be mixed forms, such as adhesive and pericardial effusion.?

Pericardial effusion

• Pericardial effusion is formed at an acute (rapidly developing) and chronic (long accumulates) versions of the disease. In addition, the effusions are classified according to the following criteria:
  • distribution in the cavity - localized (between spikes) or ambient (across the cavity);
  • effects on hemodynamics - without influence. cardiac tamponade or constriction;
  • composition content - exudate (in infectious inflammation), transudate (with noninfectious nature), blood, air, or more rarely a gas (for certain types of bacterial destruction);
  • size based on echocardiographic (heart ultrasound) assessment - Small <10 mm, 10-20 mm moderate expressed> 20 mm.
• Pericardial effusion in the pericardium can also be classified according to composition: serous (the smallest size of blood proteins) pericarditis, which is quickly absorbed and does not marking, fibrinous pericarditis, and the presence of fibrin strands (blood protein having a larger size and which plays a fundamental role in the blood coagulation system) in contents.

cardiac tamponade

• Cardiac tamponade - a serious life-threatening condition. It is the accumulation of fluid, blood, pus, gas in the pericardial cavity with the development of compression of the heart in the absence of treatment. As a result, it can not provide the blood of other organs in the required amount. As a result of their failure develops.

symptoms

Clinic pericarditis depends on the cause, the disease stage and form.

Signs of acute and chronic forms

Acute pericarditis is often characterized by pain in the heart and the pericardial friction noise, which listens stethoscope.

Pain dull and pressing, radiating to (give) in both arms, left shoulder or subclavian region that resemble stenokardicheskie. Pain aggravated by deep breathing and coughing, in the supine position and decrease when the person sitting position, breathing normally frequent, superficial.

Important! Pericarditis pain persists after nitroglycerin and similar substances. Although positively acting analgesics (NSAIDs) such as ibuprofen, diclofenac, aspirin.

Patients also complain

• shortness of breath,
• palpitations,
• general weakness,
• chills,
• dry cough,
• temperature rise.

Chronic pericarditis characterized by the same symptoms, but less pronounced form and most of its clinical depends on the number of effusion.

Signs pericardial effusion (ekssudatinaya form)

In exudative inflammation of the outer lining of the heart arise:

• pain and tightness in the chest;
• increase in shortness of breath in the accumulation of fluid around the heart;
• violation of swallowing - dysphagia;
• fever,
• hiccups.

At the expressed amount of fluid, especially with the rapid accumulation of it, developed cardiac tamponade, which is characterized by:

• severe shortness of breath;
• heart palpitations;
• hypotension - low blood pressure;
• paradoxical pulse (reduction of blood pressure by more than 10 mm Hg at inspiration during quiet breathing);
• pale skin with cyanosis;
• the appearance of a typical - face, neck and front of the chest swelling, swollen veins in the neck.

Diagnostics

Acquainted with the patient, the doctor interrogates his complaints, transferred and chronic diseases, spends inspection, listens to noise (noise of friction of the pericardium) and heart sounds, exploring the pulse, blood pressure was measured on both hands.

Pericarditis most often discovered by chance during examination for any other reason. But if the examination, the doctor suspected pericarditis, make sure you appoint a laboratory examination methods:

Clinical (general) blood test:

• may be a manifestation of inflammatory reactions of blood (increasing the number of leukocytes, the appearance of young forms, increasing ESR/РОЭ);

Urinalysis:

• signs of kidney damage when inflammation, tumors,

Blood chemistry:

• heightened C-reactive protein,
• quantity adjustment thyroid hormones,
• increase creatinine and urea in renal failure,
• positive revmofaktor - a sign of rheumatoid pericarditis,
• antinuclear antibodies in systemic lupus erythematosus,
• ALT, AST in the evaluation of liver function,
• troponins and CK-MB myocardial infarction,
• violation ratio and the amount of protein and its fractions.

The main diagnostic methods are instrumental in particular imaging techniques.

• Chest X-ray - shows an increase in heart size.
• echocardiography (Ultrasound of the heart) - the most common imaging technique with high availability. Easily visible discrepancy leaves the pericardium, the exemplary nature of the fluid in the cavity defined by the signs of cardiac tamponade, myocardial.
• Computed tomography more accurately determine the amount of content in the pericardium nature of the defeat of his leaflets, reveals a tumor, heart disease accumulation.
• Magnetic resonance or MRI of the heart with the newest technologies able to detect and characterize the pericardial tissue to determine the degree of influence of its defeat in the function of the heart.

Suspected pericarditis possible using an electrocardiogram. This first stage of diagnosis. Pericarditis the ECG is defined as the increase of common contour line segment ST.

After sufficient pericarditis visualization to determine its cause performed pericardial puncture with subsequent investigation of the obtained material. The procedure is carried out based on the severity of the condition and quantity of pericardial effusion.

Photo: inflammation of the pericardium, a photomicrograph

pericarditis treatment

Treatment of pericarditis spend cardiologists, internists, less breast or cardiovascular surgery.

The first step in treatment is to choose the mode of activity for the patient. In acute embodiment shown strict bed rest, in case of chronic pericarditis activity depends on the degree of damage to the heart. In any case, limited physical activity, appointed medical diet with a reduced content of salt and fat.

medication

In acute pericarditis, exacerbation of chronic or recurrent lesion pericardium treatment starts with a scheme: aspirin or NSAIDs (ibuprofen, indomethacin) + colchicine. In case of intolerance to first-line drugs and the exclusion of infectious causes of process administered glucocorticoids.

The deadline for this is treatment of recurrent pericarditis perikardektomiya - heart excision serous membranes. But the operation should be done only after careful evaluation of the lack of positive dynamics of drug therapy, and in the institution, which has experience of such intervention.

When purulent pericarditis added to the treatment regimen antibacterial therapy. Its antibiotic treatment is carried out inside, iv, administered drug less pericardial after evacuating the purulent contents.

In tuberculous embodiment 2-3 is used antituberculosis drug, which are assigned to six months or more.

In autoimmune, allergic and pericarditis disorers systemic connective tissue disease, Therapy consists of receiving glucocorticoids and drugs intended for the treatment of primary pathology.

surgical methods

In a situation of rapid growth of the effusion with the development of cardiac tamponade symptoms of thoracic and cardiovascular surgeon performs puncturing the pericardium with the drainage of the contents. The procedure is performed after local anesthesia and under the control echocardiogram.

• Perikardioskopiya - pericardial imaging technique with biopsy (wall tissue slices) for determining the nature and causes of failure.
• Operation on the formation of pericardial "window" - the intervention to create a hole of the pericardial space for the permanent pleural drainage and prevention of cardiac tamponade. The method used for frequent massive effusions, occurring more often in diseases caused by neoplastic processes.
• Perikardektomiya - radical method of treatment of constrictive pericarditis with pericardial removal of both sheets. The operation is performed open-heart surgery through the sternal access.

Complications and prognosis

The development of the disease and its prognosis depends on the diagnosis of the time. The earlier the patient arrives, the better. Unfortunately, there are cases when the patient turns later with the already developed complications. The most severe and life-threatening are cardiac tamponade, purulent pericarditis.

In the case of acute pericarditis, idiopathic or viral etiology, prognosis is favorable. The risks of complications (tamponade, constriction) are minimal. With insufficient treatment and incomplete use regimens may develop recurrent pericarditis.

In recurrent embodiment prognosis depends on the etiology and therapy patient adherence. With frequent relapses, exacerbations, according to the glucocorticoid quality of life is greatly reduced.

At revealing pericardial effusion prognosis also depends on the cause of development and the number of cavity contents. If echocardiography it less than 10 mm, the prognosis is favorable, in the case of a larger content of the fluid increases the risk of cardiac tamponade.