『Cardiology - Pericardial Disease』のカバーアート

Cardiology - Pericardial Disease

Cardiology - Pericardial Disease

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 Pericardial Disease Briefing Document1. Acute PericarditisDefinition: Acute pericarditis is the inflammation of the pericardium, the fibrous sac surrounding the heart.Key Characteristics & Diagnosis (at least two of four criteria):Chest Pain: Typically "sharp, severe, and positional." It is worse when supine and improves with sitting up and leaning forward. Unlike angina, it is "not exacerbated by exertion nor relieved by rest or nitroglycerin."Pericardial Friction Rub: A "hallmark of acute pericarditis," described as a "harsh, scratchy sound" with classically three components corresponding to atrial systole, ventricular systole, and ventricular filling. It is not affected by respiration, differentiating it from a pleural rub.ECG Changes: "Concave ST-segment elevation in multiple leads" that does not follow a single coronary artery distribution. "PR-segment depression in lead II or reciprocal PR-segment elevation in lead aVR" may also be present. This contrasts with acute myocardial infarction ECG findings.New Pericardial Effusion: Presence of fluid around the heart. The absence of an effusion, however, "does not exclude acute pericarditis."Causes (most often idiopathic or presumed viral):Infectious: Viral (Enterovirus, herpesvirus, adenovirus, parvovirus), Bacterial (Mycobacterium tuberculosis, Pneumococcus spp., Staphylococcus spp.), Fungal.Noninfectious: Autoimmune diseases, Cancer (metastatic lung/breast cancer, melanoma, lymphoma, leukemia), Metabolic conditions (uremia, myxedema), Drug-related (hydralazine, procainamide), Iatrogenic (cardiac surgery - postpericardiotomy syndrome, coronary perforation, pacemaker lead penetration), Other (irradiation, aortic dissection). Tuberculosis is a significant concern in endemic areas and specific patient populations.Evaluation Support:Echocardiography: Used to evaluate for pericardial effusion.CMR imaging/Gated Cardiac CT: Identifies "pericardial inflammation, characterized by pericardial thickening and late gadolinium enhancement."Serologic Evidence: Elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and leukocytosis. Serum cardiac troponin levels may be "normal or may be slightly elevated if there is a component of myopericarditis."Management:Outpatient vs. Hospitalization: Most managed as outpatients, but hospitalization is required for high-risk features like temperature >38°C, subacute onset, large effusion/tamponade, oral anticoagulation, or lack of response to treatment.First-line Therapy: Aspirin (750-1000 mg every 8 hours for 1-2 weeks) or NSAIDs (ibuprofen 600 mg every 8 hours for 1-2 weeks).Adjunctive Therapy: "Colchicine (0.5 mg once or twice daily for 3 months) is recommended as adjunctive therapy to shorten symptom duration and reduce treatment failure and recurrence."Glucocorticoids: Reserved for specific cases (recurrent, incessant, or chronic pericarditis despite standard therapy; uremic pericarditis unresponsive to dialysis; contraindications to NSAIDs; autoimmune-mediated pericarditis). Prednisone is added to standard therapy. CRP can guide tapering.Activity Restriction: Athletes should not return to competitive exercise for 3 months. Non-athletes restrict strenuous activity until symptoms resolve.2. Pericardial Effusion and Cardiac Tamponade2.1. Pericardial EffusionDefinition: Accumulation of fluid within the pericardial space. Causes: Often idiopathic, but malignancy, infections (tuberculosis in endemic areas), autoimmune disease, hypothyroidism, and iatrogenic causes should be considered. Management:Pericardiocentesis: Considered for diagnostic and therapeutic purposes if cancer or bacterial infection is suspected, or for large idiopathic effusions of >3 months' duration (due to 1 in 3 patients progressing to tamponade).Empiric Treatment: Reasonable for effusions of unknown cause with elevated inflammatory markers.2.2. Cardiac TamponadeDefinition: "Cardiac tamponade occurs when fluid accumulation within the pericardial space compresses the heart and impedes diastolic filling." It can arise rapidly with low volumes (trauma, aortic dissection) or slowly with large volumes (neoplastic disease, hypothyroidism).Clinical Presentation & Evaluation:Signs: Tachycardia, muffled heart sounds, and elevated central venous pressure (CVP). Hypotension may occur as pressures rise. The "y descent of the jugular venous pulse may be absent."Pulsus Paradoxus: A "key clinical feature," characterized by a "fall in systolic pressure of greater than 10 mm Hg during inspiration." It is not specific to tamponade.ECG: Sinus tachycardia, "electrical alternans (related to a swinging motion of the heart within the pericardial fluid)," or low voltage.Chest Radiography: "Typically enlarged cardiac silhouette (water bottle heart)" if fluid accumulated slowly.Echocardiography: Essential for diagnosis, defining fluid presence, distribution, and volume. Key findings include "Early diastolic collapse of the right ventricle, late diastolic collapse ...
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