Pericardial Effusion

Normal: 15-50 ml of thin serous fluid

Sudden increase: up to 200 ml: OK between 200 and 300 ml: can be fatal

Slow increase: up to 2 liters: OK

Cardiac Tamponade

Jugular venous distention, muffled heart sounds, hypotension, pulsus paradoxus

Echocardiogram: diastolic collapse of right atrium and right ventricle

Swan-Ganz: equalization of pressures

Acute Pericarditis

Most commonly idiopathic (viral), self-limited to 1-3 weeks with

Sharp substernal pleuritic positional pain

Pericardial friction rub

Diffuse upward concavity ST elevation

Diseases of the Pericardium

1. Pericardial effusion A. Hemopericardium B. Cardiac tamponade

2. Pericarditis A. Serous D. Hemorrhagic B. Fibrinous E. Constrictive C. Purulent

Pericardial EffusionNormal: 15-50 ml of thin serous fluid

Sudden increase: up to 200 ml: minimal increase in pressure between 200 and 300 ml: sharp rise in pressure

Slow increase: up to 2 liters: minimal increase in pressure

Pericardial Effusion: Common Causes

Viral myopericarditisMetastatic malignancyAutoimmune diseaseDrug-inducedRenal failureBleeding (Hemopericardium)

Pericardial Effusion: Symptoms

Dull constant left chest ache

Dyspnea (shortness of breath)

Less common: Hiccups (phrenic nerve) Hoarseness (recurrent laryngeal nerve) Dysphagia (esophageal compression)

Pericardial Effusion: Signs

Muffled soft heart sounds

Dullness to percussion over lower posterior left lung (Ewart’s sign)

Decrease in pericardial friction rub

Pericardial Effusion: Diagnosis

Chest x-ray: if >250 ml: enlarged globular cardiac silhouette, maybeEKG: decreased voltage, (alternating large and small QRS “electrical alternans” as electrical axis changes as heart swings to and fro in a large effusion, cute but rare)

Pericardial Effusion: Diagnosis

Echocardiogram: can provide estimate of size and evidence of tamponade

Pericardiocentesis: low yield, best reserved for cases with tamponade when simultaneously diagnostic and therapeutic

Hemopericardium

Rare, but commonly fatal

Causes: cardiac rupture after transmural myocardial infarction (especially day 5), aortic aneurysm rupture, chest trauma, anticoagulation, leukemia

Cardiac Tamponade

Pericardial effusion or blood compressing the heart enough to impair filling and pumping

Symptoms: If sudden: confusion, agitation, dyspnea, collapse, arrestIf slow: fatigue, leg edema, dyspnea

Cardiac Tamponade: Signs

Jugular venous distention, muffled heart sounds and hypotension (Beck’s triad)

Pulsus paradoxus [misnomer] exaggeration of normal decrease in blood pressure with inspiration >10 mm Hg systolic (not specific, also seen in obstructive airway disease)

Cardiac Tamponade: Diagnosis

Echocardiogram: diastolic collapse of right atrium and right ventricle

Swan-Ganz right heart catheterization: increased and equalized right atrial and left atrial (surrogate: wedge) pressures

Treatment: tap it! (subxiphoid)

Types of Pericarditis

Serous: smooth surface, scant neutrophils, lymphocytes and macrophages, usually with effusion of 50-200 ml of thin fluid (protein <50% of serum level)Fibrinous: dry, roughened, shaggy, “bread and butter” surface, more neutro- phils, lymphocytes and macrophages, serofibrinous if with effusion

More Types of Pericarditis

Purulent (synonym: suppurative): red granular surface coated with pus, lots of subsurface neutrophils, up to 500 ml exudate in the pericardiumHemorrhagic: serous, fibrinous or purulent plus hemorrhage, +/- effusion or exudate with blood addedConstrictive: [misnomer] rarely any -itis

Acute Pericarditis

The most common disease of the pericardium

Most common causes 1. Infectious A. Viral (idiopathic) B. Pyogenic bacterial C. Tuberculosis

Acute Pericarditis: Most common causes

2. Non-Infectious A. Post myocardial infarction B. Metastatic malignancy (lung, breast) C. Autoimmune connective tissue disease D. Drug-induced (e.g. procainamide) E. Radiation-induced F. Renal failure

Acute Pericarditis: Symptoms

Pain: substernal, but sharp, pleuritic (increased with inspiration), positional (increased with lying down, decreased with sitting up and leaning forward)Dyspnea: not exertional Fever(Malaise, myalgias, if viral)

Acute Pericarditis: Physical & EKG signs

Pericardial friction rub: evanescent, superficial, scratchy, to and fro, best heard with stethoscope diaphragm, with patient leaning forward, exhaling

EKG (abnormal in 90%): ST elevation diffuse (except aVR, V1) with concavity upwards, +/-PR depression

Viral (Idiopathic) Pericarditis

Self-limited, usually over in 1-3 weeksMost common viruses: Coxsackie (especially group B) or echovirus not routinely cultured, so specific diagnosis requires anti-viral titers, acute and convalescent 4-6 weeks later rarely worth doing, so viral pericarditis = idiopathic (sort of, approximately)

Acute Pericarditis due to Pyogenic Bacteria

Rare, purulent, generally fulminant

High mortality

Most common bugs: Staphylococcus aureus Streptococcus pneumoniae

Acute Pericarditis due to Pyogenic Bacteria

Pathogenesis:extension of empyema or myocardial abscess OR seeding of pre-existing effusion OR hematogenous infection

Evolution: fibrinous adhesions, organization (fibroblasts), fibrous adhesions, “constrictive pericarditis”

Post Myocardial Infarction Pericarditis: Two Forms

1. Extension of visceral pericarditis to parietal over large transmural infarct, uncommon, <5% of infarctions

2. Dressler syndrome 2-12 weeks after infarction, probably autoimmune, has become rare

Autoimmune Pericarditis: occurs in 30% of patients with lupus (as part of a polyserositis with simultaneous pleuritis and peritonitis), and with rheumatoid arthritis

Drug-induced Pericarditis: occurs with procainamide (sometimes as part of a polyserositis), and with hydralazine

Hemorrhagic Pericarditis

Rare, associated with 1. metastatic carcinoma 2. leukemia (thrombocytopenia) 3. tuberculosis

Skin test for tuberculosis (“PPD”) and chest x-ray: important tests for unexplained pericarditis

Constrictive “Pericarditis”

Encasement of the heart in a dense fibrous or fibrocalcific scar which prevents cardiac hypertrophy or dilatation

Rare, commonly due to previous purulent or tuberculous pericarditis

Pathophysiology similar to tamponade

Constrictive Pericarditis

Symptoms: fatigue, leg edema, dyspnea

Signs: jugular venous distention (increased with inspiration = Kussmaul’s sign), pericardial knock following S2, hepatomegaly, ascites, leg edema

Constrictive CardiacPericarditis Tamponade

Pulsus paradoxus No Yes

Kussmaul’s sign Yes No

Constrictive Pericarditis

EKG: atrial fibrillation (50%), low voltage

Chest x-ray: calcification (50%)

Cardiac catheterization: dip & plateau right and left ventricular tracings, right atrial prominent y descent

Constrictive Pericarditis

Differential diagnosis: restrictive cardiomyopathy

Echocardiogram, computerized tomo- graphy or magnetic resonance imaging: thickened pericardium

Treatment: strip it! (surgically)

Pericardial Effusion

Normal: 15-50 ml of thin serous fluid

Sudden increase: up to 200 ml: OK between 200 and 300 ml: can be fatal

Slow increase: up to 2 liters: OK

Cardiac Tamponade

Jugular venous distention, muffled heart sounds, hypotension, pulsus paradoxus

Echocardiogram: diastolic collapse of right atrium and right ventricle

Swan-Ganz: equalization of pressures

Acute Pericarditis

Most commonly idiopathic (viral), self-limited to 1-3 weeks with

Sharp substernal pleuritic positional pain

Pericardial friction rub

Diffuse upward concavity ST elevation

Sample Examination Question

1. The pericardial effusion most likely to be fatal is

A. Hemorrhagic slowly increased to 1500 mlB. Hemorrhagic suddenly increased to 150 mlC. Serous slowly increased to 2000 mlD. Serous suddenly increased to 100 mlE. Serous suddenly increased to 300 ml

Sample Examination Question

2. A red granular pericardial surface is characteristic of

A.Constrictive pericarditisB.Fibrinous pericarditisC.Hemorrhagic pericarditisD.Purulent pericarditisE. Serous pericarditis