Cardiology Dr Osama Mahmoud

r------------------------------------------

I

I

I

• Microbiological

evidence

of IE (blood

cultures are positive but

major criteria are not met

as previously

described, or serological

studies support

an infection

consistent with the diagnosis of IE.

Cardiotogi

I

PERICARDIAL DI!iEA!iE!i

The Pericardial Sac:

also limits distention of the heart. The pericardial sac contains up to 50 rnl of fluid.

•

The visceral layer is not sensitive to pain, but the parietal layer is sensitive.

•

The parietal layer may be insensitive, and the pain that occurs with pericarditis is due

to irritation of the pleura.

1. Viral: coxsackie - echo - infIuenzameasles -mumps

2.

Purulent

e.g.

•

Staphylococci~blood

born

(septicaemia)

3.

TB.

•

Streptococci

~ penetrating

trauma.

.

.

Carcinoma

of the breast

4. Rheumatic

fever

5. Uremia,

6. Mahgnancy~

Carcinoma

of the lung

7. Radiadtion.

8. Collagen disease. 9. Myocardial infarction

10. Drugs e.g hydralazine.

1. Pain

•

Stitching.

_...-2. Toxemia

•

Retrostemal.

3. Symptoms

of the cause

•

Radiates

to shoulders

and neck.

4. Pericardial

rub.

•

Increased by breathing, movement and

swallowing.

c::::> ECG

• Raised

S-T segment (diffuse with upward

concavity)

• Inverted

T if there is a degree

of myocarditis.

c::::> Echo: for development

of effusion.

c::::> Lab: Cardiac

enzymes

may be elevated

if there is associated myocarditis.

~ Treatmen

1. Cause

haemopericardium.

~ A pericardial rub is a high pitched

superficial

scratching or crunching noise

, it is heard during systole and may also be audible in diastole and has to-

and - fro quality.

~ Viral pericarditis may be relapsing

(relapsing

pericarditis)

CardiotOg"2 "

II. Pericardial

Effusion

Fluid

in pericardium

•

Bloody (hemopericardium):

• Trauma. • Rupture aneurysm of aorta.

•

Hemorrhagic:

• Malignant.

• TB.

• CRF.

•

Exudate:

• Viral.

• TB.

• Malignancy.

•

Transudate:

• Part of generalized edema e.g nephrotic $.

•

Chylous:

• Fluid is milky white, rich in fat.

With Sudan III it becomes

orange.

It depends

on the amount & rate of accumulation of effusion.

c::)

Small amount or large amount + rapid onset ---7

Tamponade ..

c::)

Large amount + gradual onset may gives mild S & S.

Significant

effusion (Tamponade)

i.e

effusion

interfering

with the

mechanics

of

the

heart

with impaired

filling of

the

heart and

decreased

cardiac output

---7

picture

of heart failure (J.,

COP,

PVC, SVC).

• Inspiratory filling

(Kussmaul's

sign) .

• Diastolic collapse

(Friedreich's

sign) i.e deep y descent.

@ Ascitis precox.

-> Inspection and palpation:

•

Apex is not visible or palpable.

-> Percussion:

•

Dullness

outside

the apex.

•

Wide bare area.

•

Shifting

dullness

at the 2nd left space

!?

•

Ewart's

sign: (Dullness in the left

infrascapular area due to compression

of the

left lung ---+ (left basal lung collapse)

•

Weak or distant

heart sounds.

•

X- ray:

(Flask shaped heart with sharp border).

•

Echo:

It is the best; it diagnoses also severity of effusion.

•

ECG:

Low voltage i.e amplitude of QRS complex in all limb leads < 5 mm.

• Pericardiocentesis:

It may leads to arrhythmia or injury of coronary vessels.

c) Diagnostic

+ Culture & Z.N. + Cytology

+ Chemistry

c) Therapeutic

+ To prevent fibrosis

+ To -l-l-symptoms

*Cardiac tamponade describes

picture of heart failure due to

compression of the heart by a large or rapidly developing effusion

leading to PVC, SVC and COP.

* SVC obstruction is common

in constrictive pericarditis than

pericardial effusion as constrictive

pericarditis is a chronic disease

but effusion with SVC obstruction

= tamponade (emergency).

~ Treatmen

Steroids to e adhesions !?

(••

Cause.

(••

(•.

Pericardiocentesis.

(••

Pericardiectomy.

(••

Pericardial window.

Cardio'0ei'

.,

Also, the calcification may extend to the myocardium---+

impaired myocardial

contraction.

Constrictive

pericarditis

should be suspected in any patient

with a picture

of

unexplained

right heart failure with a small heart.

~ C\p As effusion

but there are:

.:. Ascites precox.

.:. Size of the heart is smaller.

.:. AF due to decreased

ventricular filling ~ t atrial pressure

~ atrial dilatation-e Al-.

.:. Pericardial knock

(3rd heart sound) .

•:. P. Paradoxus.

.:. Kussmaul's sign and Friedreich's

sign of neck

veins.

~ Investigations

1. X-ray: ---'small

sized heart - calcification of the pericardium.

•

Antituberculous

drugs .

•

Pericardiectomy

(Improvement may be delayed after pericardiectomy)

~ C\p 1.

Associated

valve lesions.

2.

Fixed

apex,

and systolic intercostal retraction (Broadbent's sign).

3.

Manifestations

similar to constrictive

pericarditis e.g PVC,

J,

COP, svc.

~ Investigations

• Fluoroscopy screen (Ba swallow + screening)

showing kinking of oesophagus with cardiac beats.

~ Treatmen

Treatment of any associated

valvular lesions + surgery

for the pericardium.

not the result

of hypertension, congenital, or rheumatic heart disease, coronary

or pericardial

abnormalities.

.:. Alcohol abuse.

.:.

Hemochromatosis

.:. SLE.

.:. Polymyositis .

•:. Friedreich's ataxia.

.:.

Selenium deficiencyo

Adriamycin

.• :. Idiopathic

chambers

are dilated with systolic dysfunction .

.,

Biventricular dilatation .

.,

Picture

of congestive

heart failure.

- Left

sided failure

"see before"

8

- Right sided failure "see before"

Embolic manifestation,

AF may occur.

*X-ray, echo ~ilated

heart.

_

*BeG s-hQwing~nonspedfic"cha:tlges.

~ Treatmen

Systolic

dysfunction

e:::> ACE inhibitors. .

e:::> Diuretics.

e:::> Anticoa

ulant

thera

for AF or histor

of embolization.

Reversible

dilated

cardiomyopathy

may .occur ,with pregnancy,

aJcdholabtise,

selenium

deficienc

,h

oth

roidism and h

erthvroidism,

Corticosteroids

for inflammatory

cases.

e:::> Digitalis

for cases

with

AF.

e:::> Treatment of arrhythmias.

0.0: Ischemic

heart disease.

(

)

There isIithickness

of

the

interventricular

septum ~

encroachment on the aortic

opening

~

picture

of AS (subvalvular)

i.e

left ventricular

outflow tract obstruction.

{>

It is an autosomal dominant

disease.

{>

There is mainly

diastolic dysfunction.

\

{>

Mitral incompetence

may occur in this

type of cardiomyopathy

as the thickned

septum leads to abnormal movement of the

mitral valve during

systole.

Ventricular arrhythmias are thought to be responsible for many of these deaths.

•

Jerky carotid pulse because of rapid early ejection, followed by an obstruction

and then by another emptying during systole (it indicates severity).

•

There is also left ventricular hypertrophy with palpable 4th heart sound,

which gives double impulse at the apex .

•••••.•• n •• e< of HOCM:

Echocardiography.

C Left V hypertrophy involving the septum.

Systolic anterior motion (SAM) of the mitral valve.

ECG: Left V++,

Deep wide Q waves (pseudo-infarct pattern) .

•

ij-$j!i\f-jiti Vigerous exertion should be avoided (see before).

Beta blocker

and verapamil

(11 outflow obstruction), they can help

to relieve the angina and sometimes prevent the syncopal attacks.

•

Digitalis

is better

avoided as it II the outflow tract obstruction.

•

Amiodarone

for

arrythmias.

•

Vasodilators

loutflow

tract obstruction (so they are not used)

•

Surgery

myomectomy to 11 thickness of the septum.

Also, non surgical ablation of the septum can be done.

[11ltesfdci'~.~i.cal~a.i.im4abathi")

The ventricular filling

is impaired because the ventricles are stiff.

* AF as there is decline

Cardiology

in ventricular filling (stiff ventricle)

---7 i atrial pressure ---7

atrial dilatation

---7 AF.

* Congested neck veins with kussmaul's

sign and Friedreich' s sign.

* Echo ---7 diastolic

dysfunction. ,

*Endomyocardial

biopsy .

MYOCARDITI!i

I

• Coxsakie..

VIrUS. r

Myocarditis may occur several weeks

after thee nutiaini

1 vira. l intection.inf .

•

Picture of biventricular failure.(see

before)

•

Inappropriate tachycardia, muffling

of H.S.

Virchow's triad

(See hypercoagulable

state in haematology)

o

Slow venous

circulation

e.g.:

.:.

Heart failure .

•:.

Prolonged recumbency.

8

Intimal injury

e.g.:

.:.

Phlebitis.

@ Hypercoagulable state

e.g.:

.:. Polycythaemia

rubra vera .

(thrombophilia

see below)

•:. Protein C, S deficiency.

.:. Antiphospholipid $.

•:. Antithrombin

deficiency.

¢ Thrombophilia should be considered in patients with:

o Recurrent DVT.

8 Venous

thrombosis

under age of 40 years.

@ Family history of venous thrombosis.

o Arterial

thrombosis

in absence of arterial disease.

SJitres 0;1 D~~

(••

Lower limb: Ilio femoral

or popliteal veins.

1. Edema of lower limb.

2. Tender

calf muscle.

1.

DVT

2.

Cellulitis.

3.

Rupture plantaris.

4.

Rupture baker cyst.

•••

".115,'a.·i~.h ••er.al neuritis.

6.

Osteomyelitis.

4·. Radio isotope scan:

Injection of radioactive fibrinogen, the site of DVT can

be detected by Gamma camera (fibrinogen scanning).