لخّصلي

Disorders of Pericardium:
I. Pericarditis
Often local manifestation (indication) of another disease
May present as:
Acute pericarditis
Pericardial effusion (راقة )
Constrictive pericarditis( التضييقية )
Acute Pericarditis
Acute inflammation of the pericardium
Cause often unknown, but commonly caused by
infection,
uremia (renal failure),
neoplasm (tumor),
myocardial infarction (heart attack),
surgery or trauma.
Membranes become inflamed and roughened, and exudate may develop
Symptoms:
• Sudden onset of severe chest pain that becomes worse with respiratory movements and with lying down.
• Generally felt in the anterior chest, but pain may radiate to the back.
• May be confused initially with acute myocardial infarction
• Also report dysphagia (difficulty in swallowing; عسر البلع), restlessness, irritability (التهيج), anxiety (قلق), weakness and malaise (body discomfort; توعك)
• Often present with low grade fever and sinus tachycardia
• Friction rub (sandpaper sound) may be heard at cardiac apex and left sternal border and is diagnostic for pericarditis (but may be intermittent or irregular)
• ECG changes reflect inflammatory process through PR segment depression and ST segment elevation

• Treat symptoms
• Look for underlying cause
• If pericardial effusion develops, aspirate excess fluid
Acute pericarditis is usually self-limiting (محدودة ذاتيا), but can progress to chronic constrictive pericarditis
Pericardial effusion:
Accumulation of fluid in the pericardial cavity
– May be transudate (protein-poor fluid)
– May be exudate (protein rich fluid)
– May be blood
• Not clinically significant other than to indicate underlying disorder, unless:
Pressure becomes sufficient to cause cardiac compression – cardiac tamponade (Cardiac tamponade is a medical emergency. It is associated with a characteristic jugular venous pressure (JVP)

Outcome depends on how fast fluid accumulates.
• If development is slow, pericardium can stretch
• If develops quickly, even 50 -100 ml of fluid can cause problems
• When pressure in pericardium = diastolic pressure, get less filling of right atrium, less filling of ventricles, low cardiac output → circulatory collapse.

Clinical manifestations:

• Pulsus paradoxus – B.P. higher during expiration than inspiration by 10 mm Hg
• Distant or muted heart sounds
• Dyspnea (shortness of breath) on exertion
• Dull chest pain
• Observable by x-ray or ultrasound

Treatment

Pericardiocentesis
Treat pain
Surgery if cause is aneurysm or trauma

3. Constrictive (chronic) pericarditis
   • Years ago, synonymous with T.B.
   • Today, usually idiopathic, or associated with radiation exposures, rheumatoid arthritis, uremia, or coronary bypass graft (surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease)
   Pathophysiology:
   • Fibrous scarring (تندب) with occasional calcification of pericardium
   • Causes parietal and visceral layers to adhere
   • Pericardium becomes rigid, compressing the heart →↓ C.O.
   • Stenosis of veins entering atria
   • Always develops gradually
   Symptoms and Signs
   • Exercise intolerance
   • Dsypnea on exertion (shortness of breath)
   • Fatigue
   • Anorexia (eating disorder)
   • Weight loss
   • Edema and ascites
   • Distention of jugular vein (Kussmaul sign)
   • Enlargement of the liver and/or spleen
   • ECG shows inverted T wave and atrial fibrillation
   • Can be seen on imaging
   TREATMENT:
   • Drugs and diet
   Digitalis
   Diuretics
   Sodium restriction
   • Surgery to remove restrictive pericardium

Disorders of Heart Muscles

Cardiomyopathies

• Disorders of the heart muscle
• Most cases idiopathic
• Many due to ischemic heart disease and hypertension.
• Three categories:
A. Dilated ( formerly, congestive)
B. Hypertrophic
C. Restrictive
Heart loses effectiveness as a pump
A. Dilated cardiomyopathy:
B. DCM is characterized by dilation and impaired contraction of one or both ventricles
C. Most common form of cardiomyopathy accounting for one third of cases.
D. Patients have impaired systolic function (e.g. a reduced ejection fraction) and may or may not develop overt heart failure (HF).
E. ↓ C.O.; ↑ thrombi formation ; ↓ contractility, and mitral valve incompetence (عجز), arrhythmias

F. Treatment conditions: Relieve symptoms of heart failure, decrease workload, and anticoagulants; transplants

A. Dilated cardiomyopathy

DCM is characterized by dilation and impaired contraction of one or both ventricles
Most common form of cardiomyopathy accounting for one third of cases.
Patients have impaired systolic function (e.g. a reduced ejection fraction) and may or may not develop overt heart failure (HF).
↓ C.O.; ↑ thrombi formation ; ↓ contractility, and mitral valve incompetence (عجز), arrhythmias

Treatment conditions: Relieve symptoms of heart failure, decrease workload, and anticoagulants; transplants

Hypertrophic Cardiomyopathy:
• Genetic disease in which the heart muscle thickens abnormally
• The thickened heart muscle can interfere with the heart's electrical system, increasing the risk for life-threatening abnormal heartbeats (arrhythmias) and, rarely, sudden death.
Most common symptoms: shortness of breath, chest pain (angina), heart palpitations, and fainting or near-fainting (syncope), especially with physical activity.
Sometimes life-threatening abnormal heartbeats (arrhythmias) cause fainting and heart palpitations`

C. Restrictive cardiomyopathy

• Portions of the heart wall become rigid and lose their flexibility. so it's harder for the ventricles to fill with blood between heartbeats.
• Thickening often occurs due to abnormal tissue invading the heart muscle (Amyloid).

Reduced diastolic compliance of the ventricle. C.O. is normal or↓; ↑ formation of thrombi, dilation of left atrium, and mitral valve incompetence

Disorders of the Endocardium
Valvular dysfunction
• Endocardial disorders damage heart valves
• Changes can lead to :
– Valvular Stenosis = too narrow
– Valvular Regurgitation = too leaky
(or insufficiency or incompetence
• Valves that are most often affected are the mitral and aortic valves,
• but in I.V. drug users and in athletes that inject performance enhancing drugs, > 50 % involve only the tricuspid valve.
• Heart Murmur – sound caused by turbulent blood flow through damaged valves.

• Three common causes:
– Rheumatic heart disease -Streptococcus infection – damage by bacteria and auto-immune response
– Congenital malformation
– Degeneration resulting from calcification
• Blood flow obstructed from LV into aorta during systole
Causes increased work of LV
→ LV dilation & hypertrophy as compensation
→ prolonged contractions as compensation
Finally heart overwhelmed (flooded)
• → increased pressures in LA, then lungs, then right heart

Clinical manifestations
• Develops gradually
• Decreased stroke volume
• Reduced systolic blood pressure
• Narrowed pulse pressure
• Heart rate often slow and pulse faint
• Crescendo-decrescendo heart murmur
• Angina, dizziness, syncope, fatigue
• Can lead to dysrhythmias, myocardial infarction, and left heart failure

Aortic Stenosis

• Three common causes:
– Rheumatic heart disease -Streptococcus infection – damage by bacteria and auto-immune response
– Congenital malformation
– Degeneration resulting from calcification
• Blood flow obstructed from LV into aorta during systole
Causes increased work of LV
→ LV dilation & hypertrophy as compensation
→ prolonged contractions as compensation
Finally heart overwhelmed (flooded)
• → increased pressures in LA, then lungs, then right heart

Clinical manifestations
• Develops gradually
• Decreased stroke volume
• Reduced systolic blood pressure
• Narrowed pulse pressure
• Heart rate often slow and pulse faint
• Crescendo-decrescendo heart murmur
• Angina, dizziness, syncope, fatigue
• Can lead to dysrhythmias, myocardial infarction, and left heart failure

Mitral Stenosis
Most common of all valve disorders
Usually the result of rheumatic fever or bacterial endocarditis
During healing the orifice narrows, the valves become fibrous and fused, and chordae tendineae become shortened
Get decreased flow from LA to LV during filling
Results in hypertrophy of LA
Mitral Stenosis
• By causing LA to become pump:
• Get increased pulmonary vascular pressures; pressures increase through LA into lung
• Pulmonary congestion
• lung tissue changes to accommodate increased pressures
• Increased pressure in pulmonary artery
• Increased pressure in right heart
• Right heart failure

Clinical Manifestations:
• Atrial enlargement can be seen on x-ray
• Rumbling decrescendo diastolic murmur, and accentuated (prominent) first heart sound
• Dyspnea (Shortness of breath)
• Tachycardia and risk of atrial fibrillation (abnormal heart rhythm)
• Other signs and symptoms are of pulmonary congestion and right heart failure
. Aortic Regurgitation (Aortic insufficiency):
Heart condition in which the valve between the left ventricle (lower left heart chamber) and the aorta (the major blood vessel leaving the heart) malfunctions.
This valve defect allows the pumped out blood to leak back into the heart.
As a result, the left ventricle must work harder to pump more blood than normal.
Aortic Regurgitation
Some of the blood that is ejected during systole regurgitates back into the left ventricle during diastole, there is decreased effective forward flow
Causes LV to pump more blood with each contraction
→ LV hypertrophy
LV takes on “globular shape”
→ increased pressures in LA, lung, right heart
Caused by acute or chronic lesion of rheumatic fever, bacterial endocarditits, syphilis, hypertension, connective tissue disorder (e.g.Marfan syndrome) or atherosclerosis

Aortic Regurgitation: Clinical manifestations
• Widened pulse pressure (high systolic pressure, low diastolic pressure)
• Prominent carotid pulsations and throbbing peripheral pulses
• Palpitations
• Fatigue
• Dyspnea
• Angina
• High-pitched or blowing heart sound during diastole

Heart Failure
Right-sided vs. Left sided Heart Failure
• Right-sided HF
– Most common cause is left heart failure
– Can occur independently in primary lung disease conditions
• COPD, ARDS, cystic fibrosis
• Cor pulmonale (pulmonary heart disease is enlargement of the RV as a response to increased resistance or high blood pressure in the lungs)
• Left-sided HF
– Decreased output to body
– Blood backs up
Systolic vs. Diastolic HF

Systolic – decreased contraction leads to decreased output and poor perfusion of tissues
Diastolic heart failure or diastolic dysfunction refers to decline in performance of one or both ventricles of the heart during the Time phase of Diastole
Ischemic Heart Disease
Coronary Artery Disease (CAD), myocardial ischemia and myocardial infarction are progression of conditions that impair the pumping ability of the heart by depriving it of oxygen and nutrients
Coronary Artery Disease
• Any vascular disorder that narrows or occludes the coronary arteries.
• Most common cause is atherosclerosis
• The arteries that supply the heart are the first branches off the aorta
• Coronary artery disease decreases the blood flow to the cardiac muscle.
• Persistent ischemia or complete occlusion leads to hypoxia.
• Hypoxia can cause tissue death or infarction, which is a “heart attack,” which accounts for about one third of all deaths in U.S.

Coronary Artery Disease- Risk Factors:
Hyperlipidemia
Hypertension
Diabetes mellitus
Genetic predisposition
Cigarette smoking
Obesity
Sedentary life-style
Heavy alcohol consumption
Higher risk for males than premenopausal women
Myocardial infarction: ECG changes:
• Pronounced, persisting Q waves
• ST elevation
• T wave inversion
TREATMENT:
• First 24 hours crucial
• Hospitalization, bed rest
• ECG monitoring for arrhythmias
• Pain relief (morphine, nitroglycerin)
• Thrombolytics to break down clots
• Administer oxygen
• Revascularization interventions: by-pass grafts, stents or balloon angioplasty