Pericarditis

Classification according to ICD-10
I31.9	Disease of the pericardium, unspecified
ICD-10 online (WHO version 2019)

When pericarditis (also pericarditis ), in older texts and even in compositions also pericarditis is called in medicine inflammation of the connective tissue pericardium ( pericardium ). Often one finds accompanying pericardial effusion , later also fibrosis and calcifications , which can have a significant impairment of the heart function. Almost always layers of the heart muscle tissue ( myocardium ) lying directly below the pericardium are also affected by the inflammation to varying degrees ( perimyocarditis ). If the inner layer of the heart ( endocardium ) is also involved, it is called pancarditis .

Symptoms

The main symptom of acute pericarditis is often a sharp pain behind the breastbone ( retrosternal ), which increases when lying down, when moving, breathing deeply and coughing and may be accompanied by fever and tachypnea . These are typical signs of acute pericarditis sicca ( dry pericarditis ), also called pericarditis fibrinosa , which is often present at the beginning of the disease. There are only inflammatory deposits in the contact area of ​​the two pericardial leaves. When listening ( auscultation ) with the stethoscope , a scraping rubbing sound (called a pericardial rubbing sound ) over the heart is noticeable.

If a pronounced accumulation of liquid in the pericardium on - a pericardial effusion - this is called acute exudative pericarditis ( pericarditis exudative "wet pericarditis"). The painful complaints and the noise findings are typically not very pronounced. Overall, the wet form is more common than the dry form and tends to suggest an infectious cause (viruses, tuberculosis) of the inflammation. The amount of fluid can limit normal heart function to such an extent that cardiovascular insufficiency and, in extreme cases, shock can occur.

Classification

• acute pericarditis
  • serous pericarditis
  • fibrinous pericarditis
  • purulent pericarditis
  • hemorrhagic pericarditis
  • tubercular (cheesy) pericarditis

• chronic recurrent pericarditis
  • Concretio pericardii (adhesive pericarditis)
  • Accretio pericardii

• chronic constrictive pericarditis
  • Constrictio pericardii ( constrictive pericarditis, armored heart)

If exudative pericarditis does not regress, adhaesive pericarditis with adhesion disorders , rinds or swelling occurs . In the case of extensive constrictions , one speaks of pericarditis constrictiva . The Concretio pericardii denotes cord-like adhesions between the epi- and pericardium, the Accretio pericardii an adhesion of the pericardium with the environment ( mediastinum ), whereby it can hardly adapt its position to movements. The constrictio pericardii finally refers to an armored heart , which is created by a flat obliteration of the pericardium z. T. distinguished with calcifications.

Pericarditis constrictiva calcarea (“armored heart”), or pericarditis calcarea for short , can in many cases be successfully treated by surgical removal of the calcified pericardium (pericardectomy). An indication of the disease is provided by the so-called Kussmaul sign, in which the jugular vein pulse increases on inspiration in the case of constrictive pericarditis. Nowadays, the final diagnosis is made very reliably by means of echocardiography (including tissue Doppler echocardiography, TDI), computer tomography and magnetic resonance tomography.

causes

Basically, you can infectious from noninfectious different causes. Viruses are assumed to be the trigger in around 80% of all cases, even if they cannot be assigned to a clear cause.

Infectious pericarditis

Purulent / bacterial pericarditis on computed tomography. One recognizes the clear contrast medium uptake of the pericardium. As a result, a pericardial drainage was applied.

Viruses (Coxsackie A and B, adenoviruses, echoviruses, etc.) are primarily responsible for infectious pericarditis . Rare can also bacteria (aureus in purulent infections most commonly Staphylococcus, streptococcus, pneumococcus and Haemophilus influenzae, formerly often mycobacteria as part of a tuberculosis ) or as part of a sepsis and for once (about undergoing immunosuppressive therapy) and fungi to be responsible (Candida, Aspergillus) . The mycobacteria Mycobacterium tuberculosis and Mycobacterium avium-intracellulare are found in HIV patients.

Non-infectious pericarditis

Different underlying diseases come into question as causes of non-infectious pericarditis. It can occur as a complication of a heart attack ( pericarditis epistenocardica ) (see Dressler syndrome ). A distinction is made between an early form, which occurs within 24 to 48 hours, and a late form, which only becomes clinically manifest weeks to months after the heart attack.

Autoimmune diseases such as systemic lupus erythematosus , rheumatic fever , rheumatoid arthritis or sarcoid are also regularly reported as triggers of pericardial inflammation , with the endocardium and heart muscle ( myocardium ) often also being affected along with the pericardium .
Pericarditis occurs less often in the course of allergic reactions (serum sickness, drug allergy), in uremia (in the final stage) in the context of renal insufficiency or after damage from trauma or radiation therapy . Carcinomas in the heart area can lead to an inflammatory reaction of the pericardium, as can advanced metabolic diseases ( hypothyroidism with myxedema, diabetes mellitus, etc.) or cardiac surgery.

In veterinary medicine, pericarditis occurs mainly in cattle as a result of foreign bodies perforating the hood .

diagnosis

During auscultation, there is a scraping rubbing sound that typically disappears with the formation of a pericardial effusion.
The EKG shows a gradual course: initial ST elevations with raising of the J point in many leads recede again over the course. In the intermediate stage, the T waves are flattened, followed by terminal T negatives, but which usually recede completely. With a pericardial effusion, a peripheral low voltage may be seen.
In echocardiography , even the smallest amounts of effusion can be seen, and there are also thickenings of the pericardium and internal echoes as an indication of accumulations of pus.
The chest x-ray is only noticeable when there is a large amount of effusion.
A pericardial puncture could be carried out if a bacterial infection is suspected to diagnose the pathogen; degenerate cells suggest a tumor.

therapy

Bed rest and clinical and echocardiographic monitoring are indicated as basic measures in the hospital. Painkillers can be given for chest pain . Further, special measures depend on the clinical picture and the cause.

In the event of an impending pericardial tamponade (see complications), the accumulated fluid is removed with a pericardial puncture for relief . In the case of recurring, severe effusions, surgical fenestration of the pericardium may be necessary: ​​the fluid is then permanently directed into the pleura through a small incision in the pericardium.

In the event of a viral infection, nonsteroidal anti-inflammatory drugs and colchicine are given for three months . Contrary to previous practice, glucocorticoids should be avoided as far as possible, as it has been shown that they lead to an increased rate of recurrent pericardial effusions. Its administration is only indicated if there is no improvement despite treatment with nonsteroidal anti-inflammatory drugs and colchicine or if an underlying inflammatory disease is to be combated.

The administration of antibiotics (eg, doxycycline in serous pericarditis ) occurs in bacterial infections - if possible for specific pathogen (otherwise "blind" calculated, such as ceftriaxone, cefotaxime, ceftriaxone in combination with metronidazole, even imipenem or meropenem eligible). Antifungal drugs are given to treat fungal infections.

In the other forms, the respective underlying disease is treated, e.g. E.g .: immunosuppression in rheumatic fever, stabilization or improvement of kidney or thyroid function, etc.

Complications

Two complications are of particular concern:

• In the case of pericardial tamponade , large amounts of exudate from the pericardial effusion can impede the filling of the heart, resulting in congestion and cardiogenic shock . In this case, an immediate relief puncture must be performed.
• Chronic pericarditis may result after acute inflammation of the pericardium or inadequate treatment has subsided. Cicatricial adhesions and calcifications of the pericardium can also result in disorders of the ventricular filling (pericarditis constrictiva, "armored heart"). In some cases, the scarring can be removed by the heart surgeon ( Ferdinand Sauerbruch operated such an armored heart successfully for the first time in Munich). Chronic pericarditis can also cause congestion and obstruction of the outflow of the pulmonary veins, which results in pulmonary hypertension .

literature

• Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 33 f. ( Pericarditis ).
• Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid. 1986, ISBN 3-13-352410-0 , pp. 120 and 205-208.
• MC Savoia, MN Oxanan: Myocarditis and Pericarditis. In: Mandell, Douglas, and Bennett's Principle and Practice of Infectious Diseases. 6th edition 2005.
• Herbert Reindell , Helmut Klepzig: diseases of the heart and blood vessels. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 450-598, here: pp. 574-578.

Web links

Commons : Pericarditis  - Collection of Images, Videos and Audio Files

Individual evidence

1. ^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid 1986, ISBN 3-13-352410-0 , pp. 120 and 206.
2. ^ Herbert Reindell, Helmut Klepzig: Diseases of the heart and the vessels. 1961, pp. 576-578. ( The pericarditis adhaesiva ).
3. ↑ ^{a b} Massimo Imazio, Antonio Brucato, Roberto Cemin, Stefania Ferrua, Stefano Maggiolini, Federico Beqaraj, Daniela Demarie, Davide Forno, Silvia Ferro, Silvia Maestroni, Riccardo Belli, Rita Trinchero, David H. Spodick, Yehuda Adler: A Randomized Trial of Colchicine for Acute Pericarditis. In: New England Journal of Medicine. 2013, p. 130831233005005, doi: 10.1056 / NEJMoa1208536 .
4. ↑ cf. T. Butz T et al .: Constrictive pericarditis or restrictive cardiomyopathy? Echocardiographic tissue Doppler analysis. In: German Medical Weekly. Volume 133, No. 9, February 2008, pp. 399-405.
5. ↑ M. Imazio, M. Bobbio et al .: Colchicine in addition to conventional therapy for acute pericarditis: results of the Colchicine for acute pericarditis (COPE) trial . In: Circulation , 112 (13), 2005, pp. 2012-2016, PMID 16186437
6. ^ WC Little, GL Freeman: Pericardial Disease . In: Circulation , 113, 2006, pp. 1622-1632, PMID 16567581
7. ^ Ferdinand Sauerbruch, Hans Rudolf Berndorff : That was my life. Kindler & Schiermeyer, Bad Wörishofen 1951; cited: Licensed edition for Bertelsmann Lesering, Gütersloh 1956, pp. 272–275.
8. ^ Herbert Reindell , Helmut Klepzig: Diseases of the heart and the vessels. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 450-598, here: p. 579 ( functional disorders and diseases that lead to an increase in pressure in the small circulation ).

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