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 ¾Çȵǰí
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¤»óȵȴÙ.
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