Pericarditis - Causes, symptoms and treatment. MF.

Pericarditis is an inflammatory disease of the pericardium. The pericardium is the outer connective tissue of the heart that covers it from all sides, is attached to the inner surface of the chest, the diaphragm and partly to the vessels that leave the heart. The outer shell of the heart is called to perform two main functions: to preserve a certain position of the heart in space and to prevent the stretching of the heart in the event of a sudden volumetric overload.

Pericardium consists of two layers: internal( serous), tightly connected to the heart and external( fibrous), freely surrounding the heart. Between these layers, normally there are up to 20 ml of liquid, which serves as a "lubricant" to reduce the frictional force when the heart moves.

Causes of pericarditis

Depending on the cause of the onset, the following classification of pericarditis exists:

• Infectious pericarditis viral( Coxsackie, Epstein-Barr virus), bacterial( streptococcus, Neisseria), fungal( Candida fungi), parasitic( Echinococcus, Toxoplasma).Under the influence of toxins of pathogens, inflammation of the pericardial sheets and the development of a characteristic clinical picture of the disease are formed.

• Pericarditis associated with systemic or autoimmune connective tissue diseases, such as systemic lupus erythematosus, rheumatoid arthritis, systemic scleroderma. Pericarditis develops as a result of damage to the cells of connective tissue by its own protective cells in the event of a breakdown in the immunity system.
• In the spread of the inflammatory process with a number of located sites, it is also possible to develop pericarditis. This pattern is typical for acute myocardial infarction with a large amount of tissue damage or for myocarditis.
• Pericarditis can become a complication of diseases associated with severe metabolic disorders, such as end-stage renal failure, myxedema, Addison's disease.
• Traumatic pericarditis occurs with injuries or injuries of the chest cavity, as well as a complication of surgical manipulations in this area.
• Tumor pericarditis refers to the infiltration of pericardial sheets by tumor cells during the primary neoplasm of the pericardium, and also, more often, when metastases from other organs appear( lung cancer, breast cancer).

Depending on the nature of the flow, all pericarditis can be divided into( Figure 1.):
1. Acute pericarditis: • dry or fibrinous;• exudative-with cardiac tamponade-without a cardiac tamponade.
2. Subacute pericarditis: • exudative;• Adhesive;• Constrictive-with a tamponade of the heart-without a tamponade of the heart.
3. Chronic pericarditis: • exudative;• Adhesive;• Constrictive • squeezing with urge( "carapaceous heart") -with a cardiac tamponade-without a tamponade of the heart.

Figure 1. Classification of morphological forms of pericarditis.
a - dry( fibrinous) pericarditis;
b, c - exudative pericarditis;
g - adhesive( adherent) pericarditis;
d - constrictive pericarditis

Symptoms of pericarditis

Within 6 weeks of onset of the disease, pericarditis is called acute .To the fore, complaints of pain in the chest appear. The pain is intense, monotonous, almost constant. The pain is maximally expressed in the region of the heart, it increases with movement, deep breathing, it can give in the left arm, in the neck, in the region of the left scapula. The intensity of pain somewhat decreases in the sitting position, with a forward slope and with the use of non-steroidal anti-inflammatory drugs, increases in the supine position. The appearance or intensification of pain is not associated with physical exertion, the use of nitrates without effect. These specific symptoms make it possible to distinguish between ischemic heart disease and pericarditis. In addition to the patient's pain, body temperature increases, arrhythmias, lowering of arterial pressure and dyspnea at rest are possible.

In the course of the inflammatory reaction, fibrin falls on the pericardial sheets( Fig. 1, a).The appearance and constant nature of pain is associated with irritation of the nerve endings of the pericardium with fibrin falling out, as well as with the friction of the thickened layers of the pericardium during the movement of the heart. With the deposition of fibrin associated with the emergence of a specific symptom - the noise of friction of the pericardium, which is heard only at this stage of pericarditis.

The next stage of pericarditis is the accumulation of fluid in the pericardial cavity with the development of of exudative pericarditis ( Fig. 1, b, c).With a slow accumulation of fluid, there may not be significant hemodynamic changes, while rapid accumulation of exudate in certain states leads quickly to the development of a cardiac tamponade. Cardiac tamponade - compression of the heart by exudate, is a formidable complication, threatening the patient's life.

Cardiac tamponade. The arrow shows the fluid in the pericardial cavity of the

. At the same time, due to a decrease in the filling of the right heart, blood stasis is formed in the large circle of blood circulation with an increase in the liver, the appearance of edema of the lower extremities and fluid in the abdominal cavity. Because of the decrease in the volume of blood that is ejected from the left ventricle, the nutrition of all organs and tissues, especially the brain cells, is disturbed. Cardiac tamponade, as a complication of pericarditis, can be suspected with an increase in venous pressure( bulging of the jugular veins, the appearance of fluid in the abdominal cavity, pain in the right upper quadrant due to augmentation of the liver) against a background of falling arterial, the appearance of palpitation, wheezing in the absence of wheezing in the lungs.

Appearance of patient with cardiac tamponade

Without treatment, cardiac tamponade leads to patient death.

Subacute pericarditis is diagnosed within 6 weeks to 6 months of onset of the disease. In this case, pain in the chest, weakness, fever, shortness of breath are weak. Symptoms of the disease depend on the severity of the morphological changes in the pericardial sheets. of the adhesive pericarditis is characterized by the appearance of fusions between the layers of the pericardium, as well as the formation of adhesions between the heart and the walls of the chest cavity, as well as with a number of located organs( Fig. 1, d).Only with a marked adhesion process are symptoms of heart failure associated with a violation of the location of the heart in space or with its insufficient mobility.

Constrictive pericarditis occurs when the outer and inner pericardial sheets are fused over a large extent( Fig. 1, d).Formed a dense shell, embracing the heart, making it difficult to fill with blood. As a result, cardiac insufficiency arises with stagnation of blood in the area of ​​a large circle of blood circulation. If the process is significant, constrictive pericarditis can also be complicated by tamponade due to compression of the heart with a rigid pericardium.

Chronic pericarditis is diagnosed during the course of the disease for more than 6 months. It is characterized by the same morphological changes as in the subacute form. Particular attention deserves chronic constrictive pericarditis with the detoxification of , which is also very often complicated by cardiac tamponade.

Diagnosis of pericarditis

Laboratory and instrumental methods are widely used for the diagnosis of pericarditis.
In the analysis of blood, there is an increase in indicators characterizing the presence of inflammation in the body, such as ESR, blood leukocytes, lactate dehydrogenase, C-reactive protein and others. An increase in the content of troponin I and CF fraction of creatine phosphokinase in the blood indicates damage to the heart tissue.

Electrocardiography( ECG) allows you to diagnose inflammatory changes in the heart, as well as the presence of fluid in the pericardial cavity.

When radiographing chest organs, the enlarged heart is determined in an acute period, with exudative pericarditis due to accumulation of fluid.

Radiography of chest organs with exudative pericarditis

When the pericardium is compacted, the heart decreases in size, possibly the emergence of foci of detoxification. Echocardiography is the gold standard for the definition of pericardial effusion and, subsequently, the assessment of disease dynamics during treatment. In difficult cases, the computed tomography and magnetic resonance tomography of the heart is recommended.

Treatment of pericarditis

For the treatment of pericarditis, nonsteroidal anti-inflammatory drugs( indomethacin) are widely used in combination with colchicine according to a certain scheme. In the case of the proven infectious nature of the disease, antibiotic therapy is recommended. The effectiveness of treatment is estimated after 2 weeks after the start of therapy. When the condition improves, the drugs are gradually canceled. The lack of effect indicates an incorrect diagnosis of the disease, or the attachment of purulent complications.

pericardiocentesis ( puncture of the pericardial cavity) is used as a diagnostic procedure for an unclear reason for the formation of exudate, as well as for the therapeutic purpose to prevent the development of cardiac tamponade with a high volume of effusion.

Technique for pericardiocentesis

Pericardiocentesis is performed only in a stationary setting. The only contraindication for this manipulation is the exfoliating aortic aneurysm. With the help of ultrasound, a point is determined on the surface of the body closest to the exudate accumulation zone. Usually this is the area of ​​attachment of cartilage VII of the rib to the sternum. After local anesthesia, a layered puncture of the tissues is made, and the needle enters the pericardial cavity. After this, a certain amount of liquid is evacuated. Then the needle is removed, an aseptic dressing is applied. For some time the patient is under observation with a permanent visualization of the pericardial cavity. Preparation of the patient for this manipulation and subsequent rehabilitation is not required. In the case of development of severe heart failure as a result of adhesions or fusion of pericardial sheets, surgical removal of adhesions, dissection of pericardial fissures, is indicated.

Prognosis for pericardial with adequate treatment is favorable. In elderly or debilitated patients, a prolonged, relapsing course of the disease with the formation of constrictive forms is possible.

Physician therapist Sirotkina EV