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Pericardial DiseaseBy Dr. Muhammad Aftab ShahSenior Registrar Cardiology

KEMU/Mayo Hospital, Lahore.

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Pericardial Disease

• Acute Pericarditis

• Chronic Relapsing Pericarditis

• Constrictive Pericarditis

• Cardiac Tamponade

• Localized and Low Pressure Tamponade

• Restrictive Cardiomyopathy

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Pericardial Anatomy• Two major components– serosa (viceral pericardium)

mesothelial monolayerfacilitate fluid and ion exchange

– fibroa (parietal pericardium)fibrocollagenous tissue

• Pericardial Fluid– 15 - 50 ml of clear plasma ultrafiltrate

• Ligamentous attachments– to the sternum, vertebral column, diaphragm

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Pericardial Physiology

• not needed to sustain life

• physiologic functions– limit cardiac dilatation–maintain normal ventricular compliance– reduce friction to cardiac movement – barrier to inflammation– limit cardiac displacement

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Pericardial Inflammationpathogenesis

• Contiguous spread– lungs, pleura, mediastinal lymph nodes,

myocardium, aorta, esophagus, liver

• Hematogenous spread– septicemia, toxins, neoplasm, metabolic

• Lymphangetic spread

• Traumatic or irradiation

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Pericardial Inflammationpathology

• inflammation provokes a fibrinous exudate with or without serous effusion

• the normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac

• can cause pericardial scarring with adhesions and fibrosis

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PERICARDITIS

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Acute Pericarditiscommon causes

• Outpatient setting– usually idiopathic– probably due to viral infections– Coxsackie A and B (highly cardiotropic)

are the most common viral cause of pericarditis and myocarditis

– Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV

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Acute Pericarditiscommon causes

• Inpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post)

Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder

Radiation

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Acute PericarditisDiagnostic Clues

• Historysudden onset of anterior chest pain that

is pleuritic and substernal

• Physical exampresence of two- or three-component rub

• ECGmost important laboratory clue

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Chest Pain Historypericarditis vs infarction

• Common characteristics– retrosternl or precordial with raditaion

to the neck, back, left shoulder or arm

• Special characteristics (pericarditis)–more likely to be sharp and pleuritic with coughing, inspiration, swallowing– worse by lying supine, relieved by

sitting and leaning forward

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Heart Murmurs of Pericarditis

• Pericardial friction rub is pathognomic for pericarditis

• scratching or grating sound

• Classically three components:– presystolic rub during atrial filling– ventricular systolic rub (loudest)– ventricular diastolic rub (after A2P2)

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Acute PericarditisECG features

• ST-segment elevation– reflecting epicardial inflammation– leads I, II, aVL, and V3-V6– lead aVR usually shows ST depression

• ST concave upward – ST in AMI concave downward like a “dome”

• PR segment depression (early stage)• T-wave inversion– occurs after the ST returns to baseline

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Acute PericarditisManagement

• Treat underlying cause

• Analgesic agents– codeine 15-30 mg q 4-6 hr

• Anti-inflmmatory agents– ASA 648 mg q 3-4 hrs– NSAID (indomethacin 25-50 mg qid)– Corticosteroids are symptomatically

effective , but preferably avoided

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Types of Effusive Fluid

• serous– transudative - heart failure

• suppurative– pyogenic infection with cellular debris and

large number of leukocytes

• hemorrhagic– occurs with any type of pericarditis– especially with infections and malignancies

• serosanguinous

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Dignostic Evaluation

• Chest x-ray– usually requires > 200 ml of fluid– cannot distinguish between pericardial

effusion and cardiomegly

• Echocardiography– standard for diagnosing pericardial effusion– convenient, highly reliable, cost effective– false positives (M-mode)- left pleural effusion,

epicardial fat, tumor tissue, pericardial cysts

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Noncompressing Effusion

• asymptomatic unless they are large enough to compress adjacent organs– dysphagia– cough– dyspnea– hoarseness– hiccups– abdminal fullness– nausea

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Cardiac Tamponade

• Decompensated cardiac compression from increased intracardaic press

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Cardiac Tamponade

• Early stage–mild to moderate elevation of central

venous pressure

• Advanced stage intrapericardial pressure

ventricular filling, stroke volume– hypotension – impaired organ perfusion

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Beck’s Triad

• Described in 1935 by thoracic surgeon Claude S. Beck

• 3 features of acute tamponade – Decline in systemic arterial pressure– Elevation in systemic venous pressure

(e.g. distended neck vein)– A small, quiet heart

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Cardiac TamponadeBedside Diagnosis

• Elevated jugular venous pressure

• Paradoxical pulse

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Pulsus Paradoxus

• an exaggerated drop in blood pressure with inspiration (>10mmHg)

• tamponade without pulsus– atrial septal defect– aortic insufficiency– LVH with LVEDP

• pulsus without tamponade– COPD, RV infarct, pulmonary embolism

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Echocardiography

• Pericardial effusion– highly reliable

• Cardiac tamponade– RA and RV diastolic collapse– reduced chamber size– distension of the inferior vena cava– exaggerated respiratory variation of the

mitral and tricuspid valve flow velocities

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Pericardiocentesis

• Diagnostic tap– usually not indicated– rarely have positive cytology or

infection that can be diagnosed

• Therapeutic drainage– indicated for significant elevation of the

central venous pressure