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Pericarditis : The risks confronting President Yar’Adua

This is a report which presents the causes, general symptoms, diagnosis. treatments, complications as well as what is described as Dressler’s syndrome; it is meant to educate Nigerians on the risks of Pericarditis

By Sola  Ogundipe, Health Editor  &  Chioma Obinna

THE pericardium is the thin layer of specialised tissue that covers the outer surfaces of the heart. This tissue helps to anchor the heart in place, prevents excessive movement of the heart in the chest when body position changes, protects the heart from infections and tumours that develop in and may spread from nearby tissues, and may help keep the heart from enlarging.

Usually beginning as a swelling and irritation of the pericardium, pericarditis often causes a characteristic chest pain that usually compels the affected person to seek medical attention. Sometimes there are other symptoms. The condition could be sudden and short-lived (acute), but when symptoms develop more gradually or persist, the condition becomes chronic.

The sharp chest pain associated occurs when the inflamed or irritated two layers of the pericardium rub against each other. Mild cases are known to improve on their own, however, treatment for more-severe cases may include medications and, rarely, surgery. Experts say early diagnosis and treatment help to reduce  the risk of long-term complications.

King Faisal Specialist Hospital and Research centre, Jeddah, Saudi Arabia...where President Umaru Yar'Adua is being treated for pericarditis
King Faisal Specialist Hospital and Research centre, Jeddah, Saudi Arabia...where President Umaru Yar'Adua is being treated for pericarditis

Causes: Pericarditis is inflammation of the pericardium, the sac-like covering of the heart. There are many possible causes. At times it could be idiopathic (unknown cause), but often it is the result of a minor viral illness, “cold” or a mechanical injury or trauma to the heart.

If  pericarditis occurs after a heart attack, it is known as Dressler’s Syndrome (named after Polish-born American physician William Dressler who lived between 1890-1969. Other known causes include heart surgery, bacterial, fungal or viral infection including HIV, cancer tumours, rheumatoid arthritis, Systemic Lupus Erythematosus (SLE), sarcoidosis, scleroderma and metabolic diseases such as uremia (kidney failure) and hypothyroidism.

Medication reactions in the form of side effects of certain medications e.g., phenytoin, hydralazine, and procainamide that cause an immune response causing an inflammation of the pericardial sac and pericarditis. Patients who have suffered a heart attack (myocardial infarction) may develop pericarditis over subsequent days or weeks.

Kidney failure caused by the buildup of certain toxins in the body also can lead to pericarditis. Cells from tumours in other parts of the body occasionally spread (metastasize) to the pericardium, leading to irritation and inflammation.

Radiation therapy can cause pericarditis also it can develop in patients with diseases in which the immune system becomes pathologically overactive, such as rheumatoid arthritis and lupus. Tuberculosis was a relatively common cause of pericarditis in the past, but this is now rare. Some medications can trigger an immune response that causes pericarditis.

General symptoms: Chest pain is the most common symptom. The pain is usually sharp and stabbing. Evidence shows that it arises slowly or suddenly and can radiate directly to the back, to the neck or to the arm and shoulder blade. Deep breathing makes the pain worse especially when lying flat. Patient feels better when leaning forward. Pain may also occur with swallowing if the inflammation is near the gullet. Other symptoms depend upon the specific cause, such as infections which may present with fever, chills and other non-specific symptoms such as muscle aches and general malaise.

Diagnosis: The first thing a cardiologist does is to assess the quality of pain, what brings it on, what makes it better, and  where it came on gradually or quickly and what other symptoms may be present. The most common physical finding that almost always confirms diagnosis of pericarditis is a pericardial friction rub. Fluid and inflammation in the pericardial sac causes a noise that can be heard with a stethoscope over the lower border of the breastbone.

It is sometimes better heard when the patient leans forward, which causes the heart to shift to the front of the chest. The rub may not always be present and may come and go from hour to hour. Echocardiography (ECG) or ultrasound of the heart is often used to confirm diagnosis. The cardiologist looks for the presence of fluid in the pericardial sac, although in many mild cases of acute pericarditis, there is no pericardial fluid seen with echocardiography. Blood testing can be used to look for specific causes of pericarditis like infection, leukemia, kidney failure, connective tissue diseases or thyroid abnormalities.

Renal failure is an established cause of pericardial disease, including pericarditis and pericardial effusions, and a less frequent cause of chronic constrictive pericarditis
Renal failure is an established cause of pericardial disease, including pericarditis and pericardial effusions, and a less frequent cause of chronic constrictive pericarditis

Treatment: Treatment of the underlying cause of pericarditis is essential and is based on the disease process. Bed rest and medicines that reduce inflammation are the primary treatment. These include the Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and narcotics such as codeine will be needed. In recurrent cases, corticosteroids are often very effective. Pericardiocentesis, a procedure where a thin needle is inserted through the chest wall into the pericardial sac, may be considered if too much fluid is present or to aid in establishing the cause of the pericarditis (for example, infection, cancer, etc.) by analyzing the fluid that is removed. Pericardotomy (cutting a hole in the pericardial sac) or pericardectomy (removing the sac completely) may be needed for recurrent pericarditis of scarring within the pericardial sac.

Complications: Pericarditis is bad news because it is a true medical emergency if fluid fills the patient’s pericardial sac, causing enough pressure on the outside of the heart to prevent it from beating adequately to push blood to the body and lungs.

This is known as Cardiac tamponade. Essentially, the pressure within the  sac  itself needs to be higher than the pressure within the heart chambers, but symptoms gradually progress as the heart function is compromised. The symptoms of this stage tend to be nonspecific but can include shortness of breath and difficulty with exercise or doing daily activities.

Physical examination of the patient may reveal low blood pressure, dilated veins in the neck (jugular venous distention), accumulated fluid in parts of the body below the heart due to gravity (oedema), heart sounds can be muffled because the fluid in the pericardial sac blocks normal heart sounds from being heard with a stethoscope;
Cardiac tamponade may be a true emergency that is treated by pericardiocentesis, a procedure where a long needle is inserted through the chest wall into the pericardial sac and fluid is removed. This relieves the pressure within the sac and temporarily resolves the acute emergency. A plastic tube or catheter may be left in the chest until the underlying illness that cause the tamponade is addressed and further accumulation of fluid in the pericardium is prevented. Admission to the hospital is usually required.

If the heart or the pericardial sac is damaged because of trauma, or disease invades the space, then there can be scarring of the space leading to Constrictive pericarditis. This scarring can prevent the heart from expanding to collect blood from the body, limiting the ability of the heart to function and unable to collect blood and pump it to the lungs and then back to the body. The heart is constricted and cannot dilate normally and there may or may not be fluid detectable around it.

Bleeding into the pericardium from trauma or from a heart operation is the most common cause of constrictive pericarditis, but tumours, or infections like tuberculosis or fungus can also be the cause. The constriction occurs slowly over time and will cause shortness of breath on exertion and decreased ability to exercise. Swelling in the legs and the abdomen may exist because it is difficult for blood to return to the heart and fluid leaks out into the tissues.

President Umaru Yar'Adua boarding the jet with his wife on his way to Saudi Arabia.
President Umaru Yar'Adua boarding the jet with his wife on his way to Saudi Arabia.

Diagnosis is by history, physical examination, EKG, echocardiography and CT of the chest. In the event of significant scarring of the pericardial sac, pericardotomy, an operation to split open the pericardium to free up the constriction around the heart may be required to improve function. Acute episodes of pericarditis typically last from one to three weeks, but future episodes can occur. About one in five people with pericarditis has a recurrence within months of the original episode.

Dressler’s syndrome: Dressler’s syndrome is a complication that can occur following a heart attack or heart surgery. It occurs when the sac that surrounds the heart (pericardium) becomes inflamed. An immune system reaction is thought to be responsible for Dressler’s syndrome, which usually develops several weeks or months after heart tissue injury.

It causes fever and chest pain, which can feel like another heart attack. Also referred to as post-pericardiotomy and post-myocardial infarction syndrome, Dressler’s syndrome is treated with medications that reduce inflammation. With recent improvements in the medical treatment of heart attack, Dressler’s syndrome is far less common than it used to be. However, once you’ve had the condition, it may recur, so it’s important to be on the lookout for any symptoms of Dressler’s syndrome if you’ve had a heart attack, heart surgery or other heart injury.

Pericarditis : At a glance
*It is an inflammation of the lining surrounding the heart (the pericardial sac).
*Pericardial effusion is a collection of fluid in the pericardial sac. This fluid may be produced by inflammation.
*The cause in most patients is unknown, although many diseases can cause pericarditis.
*The diagnosis is made by history and physical examination including the presence of a rubbing sound heard (friction rub) with a stethoscope. It may confirmed by EKG and echocardiogram, an ultrasound examination of the heart
*Treated with anti-inflammatory medications and by treating any underlying disease.
*Pericardial tamponade occurs when enough fluid accumulates in the sac to compromise the heart’s ability to adequately pump blood.
*Tamponade is treated by pericardiocentesis, removing the fluid with a needle. Sometimes surgery is needed to strip away part or the entire pericardial sac from the heart.

King Faisal specialist hospital, Jeddah: Taking care of Yar’Adua

Mission Statement

BASED on the Council of Ministers Resolution No. 265 dated 30 Shawwal 1422H (January 14, 2002) regarding the transformation of King Faisal Specialist Hospital and Research Centre to a general organization, and according to the second article of the charter, the organization’s objectives are as follows:
*Providing the best tertiary health care.

*Contribution in the establishment of high specifications and standards for practicing medicine in Saudi Arabia.

*Conducting scientific and applied research related to health and medicine and cooperating with other specialized institutions within Saudi Arabia and abroad to develop therapeutic methodology and improve the health and medical services in Saudi Arabia in general and the medical subspecialties in particular.

  King Faisal Specialist Hospital and Research centre, Jeddah, Saudi Arabia.
King Faisal Specialist Hospital and Research centre, Jeddah, Saudi Arabia.

*Cooperating with medical institutions and educational establishments in Saudi Arabia to enhance the awareness level and health education among members of the society.

*Participating in the provision of health education programs and the training of Saudi Nationals in order to ensure an adequate number of qualified specialists.

*The provision of accredited Residency and Fellowship Programs for Saudi physicians in order for them to contribute to health care.

*The publication of periodicals and scientific medical journals.

The Heart Institute: The King Faisal Heart Institute (KFHI) is a tertiary cardiac care delivery center with international standards of excellence. Pediatric and adult patients are evaluated in highly specialized clinics by multidisciplinary staff that are uniquely trained and certifiedbyeither NorthAmericanorEuropeanBoardsin their respective medical subspecialties; patients are offered therapies consistent withdisease-specific managementguidelinesin accordance with international standards.

With its four clinical sections of Adult Cardiology, Pediatric Cardiology, Cardiac Surgery and Cardiac Surgical Critical Care, KFHI is fully capable and committed to meeting the growing needs of the Kingdom and its people for all types of cardiovascular diseases thereby minimizing, if not totally eliminating referrals abroad, through team-oriented, evidence-based practice by the use of advanced informatics systems, cutting-edge research and advanced education.

Expertise: The Congenital Heart Programme of KFHI is renown worldwide with its unmatched quality care in pediatric cardiology and pediatric cardiac surgery. Adult cardiac care program encompassing adult cardiology and adult cardiac care surgery provides cardiac care treatment to high risk patients with the most complicated diseases not available anywhere in the region.

At the KFHI, numerous catheter-based interventional procedures and surgical operations are performed on a daily basis from simple repair of a heart anomaly to the most complex and rare cardiac malformation in neonates, infants, children and adolescents. Multidisciplinary teamwork has been the key element in producing the best outcomes better than international standards.


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