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Pericarditis

Figure A shows the location of the heart and a normal heart and pericardium (the sac surrounding the heart). The inset image is an enlarged cross-section of the pericardium that shows its two layers of tissue and the fluid between the layers. Figure B shows the heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.

Graphic credit: National Heart Lung and Blood Institute (NIH) – National Heart Lung and Blood Institute (NIH), Public Domain, https://commons.wikimedia.org/w/index.php?curid=29590112

 

Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart). Symptoms typically include sudden onset of sharp chest 1) ___. The pain may also be felt in the shoulders, neck, or back. It is typically better sitting up and worse with lying down or breathing deep. Other symptoms may include fever, weakness, palpitations, and shortness of breath. Occasionally onset of symptoms is gradual. The cause of pericarditis is believed to be most often due to a viral infection. Other causes include bacterial infections such as tuberculosis, uremic pericarditis, following a heart attack, cancer, autoimmune disorders, and chest trauma. The cause often remains unknown. Diagnosis is based on the chest pain, a pericardial rub, specific 2) ___ changes, and fluid around the heart. Other conditions that may produce similar symptoms include a heart attack.

 

Treatment in most cases is with NSAIDs and possibly colchicine. Steroids may be used if those are not appropriate. Typically, symptoms improve in a few days to weeks but can occasionally last months. Complications can include cardiac tamponade, myocarditis, and constrictive pericarditis. It is a less common cause of chest pain. About 3 per 10,000 people are affected per year. Those most commonly affected are 3) ___ between the ages of 20 and 50. Up to 30% of those affected have more than one episode. The characteristic pain of pericarditis includes substernal or left precordial pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in). The pain may resemble the pain of angina pectoris or 4) ___ attack, but differs in that pain changes with body position, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Acute myocardial 5) ___ electrocardiogram (heart attack) can also cause pericarditis, but the presenting symptoms often differ enough to warrant diagnosis.

 

The classic sign of pericarditis is a friction rub heard with a 6) ___ on the cardiovascular examination usually on the lower left sternal border. Other physical signs include a patient in distress, positional chest pain, diaphoresis (excessive sweating), and possibility of heart failure in form of pericardial tamponade causing pulsus paradoxus, and the Beck’s triad of low blood pressure (due to decreased cardiac output), distant (muffled) heart sounds, and distension of the jugular vein (JVD). Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in patients who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration), low blood 7) ___ (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid. In such cases of cardiac tamponade, diagnostic tools such as an ECG or Holter monitor will then depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that cannot pump out 8) ___ effectively.

 

The diagnosis of tamponade can be confirmed with trans-thoracic echocardiography (TTE), which should show a large pericardial effusion and diastolic collapse of the right ventricle and right atrium. Chest X- 9) ___ usually shows an enlarged cardiac silhouette (“water bottle“ appearance) and clear lungs. Pulmonary congestion is typically not seen because equalization of diastolic pressures constrains the pulmonary capillary wedge pressure to the intra-pericardial pressure (and all other diastolic pressures).

 

In the developed world viruses are believed to be the cause of about 85% of cases. In the developing world tuberculosis is a common cause but it is rare in the developed world. Viral causes include coxsackievirus, herpesvirus, mumps virus, and HIV among others. Pneumococcus or tuberculous pericarditis are the most common bacterial forms. Anaerobic bacteria can also be a rare cause. Fungal pericarditis is usually due to histoplasmosis, or in immunocompromised hosts Aspergillus, Candida, and Coccidioides. The most common cause of pericarditis worldwide is infectious pericarditis with 10) ___.

 

Myocarditis

 

Pericarditis

 

Myocarditis and Pericarditis: Khan Academy

 

Answers: 1) pain; 2) electrocardiogram; 3) males; 4) heart; 5) infarction; 6) stethoscope; 7) pressure; 8) blood; 9) -ray; 10) tuberculosis

 

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