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Acute pericarditis

* ÀÓ»óÀû ¹× ¿øÀÎÀû ºÐ·ù(Fig 239-1)

* cardinal manifestations

: pain, pericardial friction rub, ECG changes, pericardial effusion with cardiac tamponade

paradoxical pulse

1) chest pain

acute infectious pericarditis¿¡¼­ ÈçÈ÷ °üÂûÇÒ¼ö ÀÖÀ¸¸ç ¸¹Àº ÇüÅ¿¡¼­ hypersensitivity or

autoimmunity¿Í °ü·ÃÀÖ´Ù.

* painless pericarditis

i) slowly developing Tbc

ii) postirradiation

iii) neoplastic

iv) uremic pericarditis

* pain nature

often severe, retrosternal & Lt precordial pain

back & Lt trapezius ridge·Î refer

pleural inflmmationµ¿¹Ý

inspiration, cough, body position change, supine position¿¡¼­ ¾ÇÈ­µÇ°í

sitting up & leaning forward½Ã relieve

2) pericardial friction rub

most important physical sign

high-pitched, scratching and grating

expiration & sitting position¿¡¼­ °¡Àå ÈçÈ÷ µéÀ»¼ö ÀÖ´Ù.

3) ECG(massive effusionÀÌ ¾øÀ» ¶§)

acute subepicardial inflammationÀ¸·Î ÀÎÇÑ 2Â÷Àû º¯È­°¡ ³ªÅ¸³­´Ù.

widespread ST elevation(upward concavity)

(2-3°³ standard limb leads & V2-6 with reciprocal depression only in aVR & sometimes V1)

QRS complex : no significant change

¼öÀÏÈÄ ST segment normalize, ±×´ÙÀ½ T wave inversion

cf. ¹Ý´ë·Î AMI¶§´Â reciprocal ST depressionÀÌ more prominent

QRS change(+), ƯÈ÷ Q wave

T wave inversion¹ß»ýÈÄ ST segment normalize

* sequential ECG : °¨º°¿¡ À¯¿ëÇÏ´Ù.

AMI : elevated ST°¡ ¼ö½Ã°£³»¿¡ Á¤»óÈ­µÈ´Ù.

widespread ST elevationÀÌ ÀÖÀ»¼ö ÀÖÀ¸¸ç Lt precordial lead¿¡¼­ most prominentÇÏ´Ù.

±×·¯³ª À̶§ T wave´Â tall & ST/T ratio < 0.25

Acute pericarditis : ST/T > 0.25

PR segment depression : atrial involvement¹Ý¿µ

Pericardial effusion

heart sound°¡ Èñ¹ÌÇØÁö°í friction rubÀÌ ¼Ò½ÇµÈ´Ù.

apex impulse°¡ »ç¶óÁöÁö¸¸ ¶§·Ð palpable

Lt lung base°¡ pericardial fluid¿¡ ÀÇÇØ ´­·Á¼­ Ewart's signÀÌ ³ªÅ¸³ª±âµµ ÇÑ´Ù.

: Lt scapula angle¾Æ·¡¿¡ a patch of dullness

CXR : "water-bottle" configuration

cardiac surgery & MIÈÄ¿¡ ÈçÇÏ´Ù.

Áø´Ü : Echo- most effective

pericardiocentesis : °ÅÀÇ Ç×»ó exudate

* bloodyÇÒ °æ¿ì : Tbc or tumor¿¡¼­ ÈçÇÏ´Ù.

±×¿Ü¿¡ rheumatic fever, post-cardiac injury, post-MI(ƯÈ÷ anticoagulant»ç¿ëÀÚ¿¡¼­)

uremic pericarditis

transudate : heart failure

Cardiac tamponade

* 3 most common cause : neoplastic, idiopathic, uremia

±×¿Ü> cardiac operation, traumaÈÄ bleeding

Tbc, hemopericardium(acute pericarditis¿¡¼­ anticoagulant txÈÄ)

* 3 principle features

intracardiac pr¡è, ventricular filling limitation¡è, C.O¡é

* tamponade¸¦ÀÏÀ¸Å°´Âµ¥ ÇÊ¿äÇÑ ¾ç

: ±Þ¼ÓÈ÷ ¹ß»ýÇÒ¶§´Â 200 mL¸¸ µÇ¾îµµ »ý±æ¼ö ÀÖ°í

õõÈ÷ »ý±æ¶§´Â 2000mLÀÌ»ó µÇ¸é ¹ß»ýÇÑ´Ù.

arterial pr¡é, venous pr¡è, faint heart sound¿Í °°Àº ÀüÇüÀû ¼Ò°ßÀº cardiac trauma or

rupture¿Í

°°Àº severe, acute tamponade¿¡¼­ ÈçÈ÷ ¹ß»ýÇÑ´Ù.

* tamponade¸¦ ÀǽÉÇØ¾ß ÇÏ´Â °æ¿ì

hypotension, JVP¡è, prominent x descent(constrictive pericarditis¿¡¼­´Â y descent)

* ±âŸ ÀÌÇÐÀû ¼Ò°ß

Kussmaul sign(-), pericardial knock(-)

paradoxical pulse(+), QRS amplitude¡é, electrical alterans

* Paradoxical pulse

inspiration½Ã RV enlargmentµÇ¸é¼­ LV compression & LV volume°¨¼Ò

-> C.O°¨¼Ò -> BP down

RV infarction¿¡¼­ hypotension, JVPÁõ°¡, y descent°¡ ¾ø´Ù´Â Á¡ÀÌ cardiac tamponade¿Í

À¯»çÇϳª

pulsus paradoxicus°¡ °¡²û ³ªÅ¸³ª°í

x-descent(-)

low voltage(-)

electrical alterans(-) µîÀÌ Â÷ÀÌÁ¡ÀÌ´Ù.

- cardiac tamponade¿Ü¿¡ paradoxical pulse¸¦ º¸Àϼö ÀÖ´Â »óȲ

i) constrictive pericarditis(1/3)

ii) hypovolemic shock

iii) acute & chronic obstructive airway disease

iv) pulmonary embolism

¡Å no pathognomonic

* low-pressure tamponade : mild tamponade

asymptomatic or mild weakness & dyspnea

Áø´Ü-echo

pericardiocentesisÈÄ hemodynamic & clinical manifestations improve

* Áø´Ü : Áï½Ã Echo½ÃÇà

inspirationµ¿¾È RV diameterÁõ°¡, LV diameter & mitral valve opening°¨¼Ò

Á¾Á¾ RV cavity diameter°¡ °¨¼ÒµÇ±âµµ ÇÑ´Ù.

late diastolic inward motion(collapse) of RV free wall & RA

Doppler : inspiration½Ã pulmonic(and tricuspid) flow¡è

reciprocal change in aortic(& mitral) flow Fig 239-2

cf. Constrictive pericarditis¿¡¼± º¸À̳ª tamponade¿¡¼± º¸ÀÌÁö ¾Ê´Â ¼Ò°ß

: PCWP, RA, RV, PA diastolic prÀÇ pressure "equalization"

-> "square root" sign in the ventricular pressure pulse

& prominent y descent in atrial & JVP

* Ä¡·á - pericardiocentesis

recurrent tamponade : surgical drainage through a limited thoracotomyÇÊ¿ä

Viral or idiopathic form of acute pericarditis

coxsackievirus A or B

influenza, echovirus, mumps, HSV, chickenpox, adenovirus, EBV µî..

´ëºÎºÐ virusµ¿Á¤Àº ¾î·Á¿ì¹Ç·Î acute idiopathic pericarditis¶õ ¿ë¾î¶ó ´õ ÀûÀýÇÏ´Ù.

AIDSȯÀÚ¿¡¼­ ÈçÇÑ ÇÕº´ÁõÀε¥

HIV ÀÚü¿¡ ÀÇÇØ¼­, opportunistic infection(CMV or Tbc), associated neoplasm(lymphoma

or Kaposi's sarcoma)

young adult¿¡¼­ more frequent

viral illness 10-12ÀÏÈÄ fever, precordial painÀÌ µ¿½Ã¿¡ ¹ß»ý(MI´Â painÈÄ¿¡ fever¹ß»ý)

fever : mild to moderate, °£È¤ 40¡É±îÁö ¿À¸£±âµµ ÇÑ´Ù.

pericardial friction rub

ST segment : 1ÁÖ ÀÌÈÄ ¼Ò½ÇµÇÁö¸¸ abnormal T wave´Â ¼ö³â°£ Áö¼ÓÇϱ⵵ ÇÑ´Ù.

pleuritis, pneumonitis°¡ ÈçÈ÷ µ¿¹ÝµÈ´Ù.

*Ä¡·á : no specific tx

bed rest & antiinflammatory tx(aspirin) ÃÖ´ë 900mg qid

-> È¿°ú°¡ ¾øÀ¸¸é NSAID(Indomethacin 25-75mg qid) or glucocorticoid(Pd 40-80mg

daily)

anticoagulant´Â ±Ý±â

Áõ»óÀÌ ¾ø¾îÁö°í ÇÑÁÖµ¿¾È ¿­ÀÌ ¾È³ª¸é antiinflammatory agent : tapering

multiple, frequent, disabling, 2³âÀÌ»ó Áö¼ÓµÇ¸é pericardiectomy°¡ È¿°úÀûÀÌ´Ù.

Post-cardiac injury syndrome

cardiac opÈÄ : postpericardiotomy syndrome

cardiac traumaÈÄ : stab wound, contusion

perforationÈÄ, µå¹°°Ô´Â MIÈÄ

pain : ÁÖ·Î injuryÈÄ 1-4ÁÖÈÄ¿¡ ¹ß»ýÇÏÁö¸¸ ¼ö°³¿ùÈÄ¿¡ ¹ß»ýÇÒ¼öµµ ÀÖ´Ù.

Àç¹ßÀÌ ÈçÇϰí injuryÈÄ 2³âÀÌÈÄ¿¡µµ ÀϾ ¼ö ÀÖ´Ù.

fever(40¡É±îÁö), pericarditis, pleuritis & pneumonitis : 1-2ÁÖ³» subside

fluid- serosangineous

arthralgiaµ¿¹Ý, tamponade´Â °ÅÀÇ ÀÏÀ¸Å°Áö ¾Ê´Â´Ù.

leukocytosis, ESR¡è

Mx : hypersensitivity reaction

Ä¡·á : aspirin & analgesics

DDx

¨ç acute MI complication(acute fibrinous pericarditis)

infactÈÄ 4Àϳ» fever, pain & a friction rub¹ß»ý

cf. Dressler's syndrome: MIÈÄ 1-2ÁÖÈÄ ¹ß»ýÇÏ´Â post-cardiac injury pericarditis

¨è pericarditis secondary to post-cardiac injury(MIÈÄ ¼öÁÖ³» ¹ß»ý)

¨é pericarditis due to collagen vascular disease

ÈçÇÑ °Í : SLE or drug-induced(procainamide or hydralazine) lupus

±âŸ : rheumatoid arthritis, scleroderma, polyarteritis nodosa

¨ê acute rheumatic fever : pancarditis, cardiac murmur

¨ë pyogenic(purulent) : opÈÄ, immunosuppressive tx, esophageal rupture,

I.E¿¡¼­ ring abscess rupture

¨ì Tbc pericarditis

¨í uremic pericarditis : chromic uremiaȯÀÚÀÇ 1/3, pain(-)

antiinflammatory agent + intensive hemodialysis

¨î neoplastic disease : metastatic tumor invasion

mc : lung, breast cancer, malignant melanoma, lymphoma, leukemia

¨ï mediastinal irradiation

Chronic pericardial effusions

¨ç Tbc : common cause

¨è other : myxedema, cholesterol pericardial ds, neoplasm, SLE, RA, mycotic infection

radiation tx, pyogenic infection, severe chronic anemia

chylopericardium

Grossly sanguineous fluid

mc = neoplasm, Tbc, uremia or slow leakage from an aortic aneurysm

Chronic constrictive pericarditis

1. ¿øÀÎ

acute fibrinous or serofibrinous pericarditis or chronic pericardial effusionÀÌ healingµÇ¸é¼­

granulation tissue°¡ Çü¼ºµÇ¾î »ý±ä´Ù.

* ¿øÀÎ Tbc

±×¿Ü : purulent infection, trauma, cardiac operation, mediastinal irradiation,histoplasmosis

neoplastic disease(lung, breast ca, lymphoma)

acute viral or idiopathic pericarditis

RA, SLE & CRF with uremia

* basic physiologic abnormality

: ventricular fillingÀå¾Ö

early diastoleµ¿¾È¿¡´Â ±¦Âú´Ù°¡ pericardiumÀÇ eleastic limit¿¡ µµ´ÞÇÒ ¶§ °©ÀÚ±â v

ventricular fillingÀÌ °¨¼ÒÇÑ´Ù.

cf. cardiac tamponade : Àü diastoleµ¿¾È venricular fillingÀå¾Ö

central venous pressure : M-shape(=prominent x & y descent)

cf. cardiac tamponade¿¡¼± y descent°¡ ¾ø´Ù.

Cath : "square root" sign during diastole

Ư¡ÀûÀÌÁö¸¸ not pathognomonic

¡ñ restrictive CMP¶§µµ °üÂûµÇ¹Ç·Î

2. Clinical & Lab findings

exertional dyspnea & orthopnea

acute pul. edema´Â ¸Å¿ì µå¹°´Ù.

Kussmaul's sign(+)

cf. Kussmaul sing(+) : TS, RV infarction, restrictive CMP

paradoxical pulse : 1/3

congestive hepatomegaly & hepatic dysfunction : ascites°¡ dependent edemaº¸´Ù ´õ

ÈçÇÏ´Ù.

heart sound°¡ distant

pericardial knock : AV closure 0.09-0.12ÃÊÈÄ

congestive splenomegaly

protein-losing enteropathy ¡ñlymphatic drainageÀå¾Ö

ECG : low voltage QRS, diffuse flattening or inversion of the T wave

P mitrale

AF(1/3)

CXR : normal or slightly enlarged heart

pericardial calcification

echo ; pericardial thickening, atrial enlargement

IVC, hepatic vein dilatation, normal systolic function

Doppler : inspiration½Ã TV flow>MV flow

expiration½Ã TV flow<MV flow

CT & MRI : pericardial thickeningÀ» º¸´Âµ¥´Â echoº¸´Ù ³´´Ù. ƯÈ÷ CT

3. DDx

¨ç cor pulmonale

¨è TS

¨é restrictive CMP

4. Ä¡·á

¨ç pericardial resection : only definite tx

¨è preop : sodium restriction & diuretics°¡ À¯¿ë

op mortality°¡ 3-10%(severe, advanced ds¿¡¼­)

¡Å ¼ö¼úÀº °¡±ÞÀû Ãʱ⿡ ½ÃÇàÇÏ¿©¾ß ÇÑ´Ù.

Other disorders of the pericardium

1) pericardial cyst : Rt cardiophrenic angle¿¡ °¡Àå ÈçÈ÷ »ý±â¸ç Áõ»óÀº ¾ø´Ù.

ÀÓ»óÀû Á߿伺Àº tumor, ventricular aneurysm, massive cardiomegaly·Î ¿ÀÀÎÇÒ¼ö ÀÖ´Ù´Â

°ÍÀÌ´Ù.

2) tumor

´ëºÎºÐ secondary

mc primary malignant tumor : mesothelioma