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Pericarditis (Pharmacology (Non-steroidal Anti-inflammatory Drugs
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Pericarditis
Pharmacology
Non-steroidal Anti-inflammatory Drugs
- This class of drug is considered along side the first line of defence in the aid against the inflammation cycle on the pericardium. This can include ibuprofen, aspirin, and indomethacin.
Colchicine
- Binds to the white blood cells and inhibits the polymerization of tubulin specifically in neutrophils. This interferes with the chemotaxis and phagocytosis which decrease the inflammation cycle caused in acute and recurrent pericarditis.
Corticosteroid
- This is a rapid response treatment used in viral and idiopathic pericarditis, which suppresses the cause and therefore relieve the symptoms. This treatment should only be used in severe acute pericarditis for instant relief as the cause of the condition may resurface and therefore recurrence is high.
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Emergency Treatment
Surgical Treatment
- Pericardiectomy is a last resort in chronic constrictive pericarditis, when drug therapy discontinues to be effective. Pericardiectomy may require more than one operation to be successful.
Drug Therapy
- Non-steroidal anti-inflammatory drugs (NSAID) may be used as a first line of defence in conjunction with colchicine, therefore suspected prehospital pericarditis (or associated symptoms) may be treated with this class of drug.
- The major first line drug defence is colchicine. This is considered in patients who do not have kidney or liver problems as toxicity can be an issue. Certain medications may interact or impair colchicine, therefore doctors approval is a must before commencement of medication.
- Corticosteroids are a last resort drug therapy for acute patients, as this treatment has a high risk of recurrent pericarditis. #
Developing Countries
- Tuberculosis is the most common cause of pericarditis, which has a higher presence in developing regions. In most cases HIV may also be present, this leads to a higher mortality rate if not diagnosed early.
Western Countries
Non-infectious
- Acute non-infectious cases are often a result of cardiac trauma, neoplastic (mutation of cells, causing them to multiply), and autoimmune diseases.
Infectious
- Are a result of viral infections. Principle infections may include influenza, hepatitis B, hepatitis C, HIV, rubella, varicella, mumps, and echovirus to name a few.
- These viral infections may cause direct damage to the pericardium or initiate the immune response (inflammation). Although this is known most viral infections are still idiopathic.
Pericardium Anatomy
Consists of the fibrous pericardium (outer sac), and the serous pericardium (double layered inner sac) which surround the myocardium. The pericardium is anchored to the diaphragm, sternum and anterior mediastinum to provide support, where as the inner layer adheres closely with the myocardium. Between these layers is the pericardial space which is are filled with 15-50ml of serous fluid to provide protection and reduce friction to the myocardium.
Pericardial Effusion
- The additional accumulation of fluid in the pericardial space creating an increased pressure, therefore constricting the myocardium.
- Tuberculosis is the major cause of pericardial effusion in pericarditis, however viruses and blunt trauma may contribute to this.
- Pericardial effusion may not be present in all patients.
Constrictive Pericardium
- Constriction of the myocardium could be result of scarred, thickened, or calcified pericardium tissues as a result of viral infections, diseases, and cardiac surgery or trauma.
Decreased Cardiac Stroke Volume
- As a result of pericardial constriction, the intrathoracic pressure during inspiration decreases (instead of increasing), causing diastolic pressure to be elevated in the atrium and ventricles. The atrial pressure causes rapid early diastolic filling. At mid-diastole the increased pressure ceases ventricular filling which continues through to diastole. This results in decreased stroke volume, effecting the systemic circulation.
Presentation
Signs and Symptoms
- Dyspnoea and a dry cough, as a result of increased intrathoracic pressure.
- Chest pain, which may radiate to the shoulders and trapezius. This pain is due the constrictive pericardium.
- A fever may be present as part of the immune response.
- Tachycardia may be present as a result of hypotension.
- Relieved chest pain when seated forward, as the diaphragm relaxes it allows additional thoracic space and therefore relieving excess pressure.
- Friction rub upon auscultation. This is caused by the inflamed pericardial layers and the myocardium rubbing together.
- Pericardial effusion. This can be viewed via an echocardiogram, however may not be present in all cases.
- A potential mimic of a myocardial infarction via an ECG, however this will be present in all leads except AVR, and in most cases V1.
- Chronic constrictive pericarditis may also include cachexia and hypotension due to decreased ventricular filling.
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Risk Factors
Recurrences
- In acute pericarditis patients, the risk of recurrences is between 20% - 50%
- Patients not treated with colchicine are at higher risk.
Viral Infections
- Attack or direct the inflammation process to the pericardium.
Post Cardiac Surgeries
- This can be a direct result of injury or scarring the pericardium during surgery initiating immune response of the inflammation cycle.
Cardiac Trauma
- Myocardial infarction and blunt force trauma.
Tuberculosis
- Is the prevailing cause of pericarditis in developing countries where tuberculosis continues to be a major health issue.
Drugs and toxins
- Phenytoin (anti-seizure medication), blooding thinning and anti-arrhythmic medications may trigger the inflammation process around the pericardium.
Less common risks
- These may include systemic fungal infections (must be in the presence of immunodeficiency virus to be effective), bacterial infections (the introduction of antibiotics creates minimal risks), active cancer, and radiation of the chest.