Pericardial Disease

The normal pericardium is a double-layered sac

1. Visceral pericardium is a serous membrane that is separated by a small quantity (15–50 mL) of fluid

2. Fibrous parietal pericardium

1. The normal pericardium, by exerting a restraining force, prevents sudden dilation of the cardiac chambers, especially the right atrium and ventricle, during exercise and with hypervolemia.

2. Restricts the anatomic position of the heart, minimizes friction between the heart and surrounding structures,prevents displacement of the heart and kinking of the great vessels,

3. Retards the spread of infections from the lungs and pleural cavities to the heart.

Total absence of the pericardium, either congenital or after surgery, does not produce obvious clinical disease.

Acute PericarditisChest pain1. Severe, retrosternal and left

precordial, and referred to the neck, arms, or left shoulder

2. Pleuritic3. Pericardial pain may be relieved

by sitting up and leaning forward and is intensified by lying supine

Pericardial friction rub 1. Audible in about 85% of these

patients2. Heard most frequently at end

expiration with the patient upright and leaning forward

3. Inconstant

ECG1. Widespread elevation of the ST

segments, often with upward concavity

2. Reciprocal depressions only in aVR and sometimes V1

3. Depression of the PR segment below the TP segment

Cardiac enzymes

I. Infectious pericarditisA. Viral (coxsackievirus A and B, echovirus, mumps, adenovirus, hepatitis, HIV) B. Pyogenic (pneumococcus, streptococcus, staphylococcus, Neisseria, Legionella) C. Tuberculous D. Fungal (histoplasmosis, coccidioidomycosis, Candida, blastomycosis) E. Other infections (syphilitic, protozoal, parasitic)

II. Noninfectious pericarditisA.Acute myocardial infarction B. Uremia C. Neoplasia D. Myxedema E. Cholesterol F. ChylopericardiumG. Trauma (1. Penetrating chest wall 2. (Nonpenetrating H. Aortic dissection (with leakage into pericardial sac) I. Post irradiation

III. Hypersensitivity or autoimmunity A. Rheumatic fever B. Collagen vascular disease (systemic lupus

erythematosus, rheumatoid arthritis, ankylosing spondylitis, scleroderma, acute rheumatic fever,

C. Drug-induced (e.g., procainamide, hydralazine, phenytoin, isoniazide, minoxidil, anticoagulants)

D. Post-cardiac injury 1. Postmyocardial infarction (Dressler's

syndrome) 2. Postpericardiotomy 3. Posttraumatic

Classification of Pericarditis

I. Acute pericarditis (<6 weeks) II. Subacute pericarditis (6 weeks to 6 months)

III. Chronic pericarditis (>6 months)

RxPatients with acute pericarditis

should be observed frequently for the development of an effusion; if a large effusion is present, the patient should be hospitalized

Nonsteroidal anti-inflammatory drugs such as ibuprofen (400–600 mg tid), indomethacin (25–50 mg tid), or colchicine (0.6 mg bid), Glucocorticoids (e.g., prednisone, 40–80 mg daily)

Postcardiac Injury SyndromePrevious injury to the

myocardium with blood in the pericardial cavity.

After a cardiac operation (post pericardiotomy syndrome), after blunt or penetrating cardiac trauma or after perforation of the heart with a catheter.

After AMI

The principal symptom is the pain of acute pericarditis, which usually develops 1 to 4 weeks after the cardiac injury (1 to 3 days after AMI) but sometimes appears only after an interval of months

Pericarditis, fever with temperature up to 39°C (102.2°F), pleuritis, and pneumonitis

Cardiac Tamponade

Cardiac TamponadeThe accumulation of fluid in the

pericardial space in a quantity sufficient to cause serious obstruction to the inflow of blood to the ventricles results in cardiac tamponade.

This complication may be fatal if it is not recognized and treated promptly.

The three most common causes of tamponade are neoplastic disease, idiopathic pericarditis, and renal failure

Bleeding into the pericardial space after cardiac operations, trauma, and treatment of patients with acute pericarditis with anticoagulants

Beck's triad: hypotension, soft or absent heart sounds, and jugular venous distention

Electrical alternans of the P, QRS, or T waves should raise the suspicion of cardiac tamponade

Paradoxical PulseGreater than normal (10 mmHg)

inspiratory decline in systolic arterial pressure

RxPericardiocentesisPericardial window

Constrictive Pericarditis

1. acute or relapsing viral or idiopathic pericarditis,

2. trauma with organized blood clot, 3. cardiac surgery of any type, 4. mediastinal irradiation, 5. purulent infection, 6. neoplastic disease (especially breast

cancer, lung cancer, and lymphoma), 7. rheumatoid arthritis, SLE, 8. chronic renal failure with uremia

treated by chronic dialysis

In constrictive pericarditis, ventricular filling is unimpeded during early diastole but is reduced abruptly when the elastic limit of the pericardium is reached, whereas in cardiac tamponade, ventricular filling is impeded throughout diastole

RESPIRATORAY VARIATION

Weakness, fatigue, weight gain, increased abdominal girth, abdominal discomfort, and edema are common.

The patient often appears chronically ill, and in advanced cases there are anasarca, skeletal muscle wasting, and cachexia. Exertional dyspnea is common

The cervical veins are distended and venous pressure may fail to decline during inspiration (Kussmaul's sign).

Congestive hepatomegaly is pronounced and may impair hepatic function and cause jaundice;

Ascites is common and is usually more prominent than dependent edema

Constrictive Pericarditis

Tamponade Characteristic

Usually absent Common Pulsus paradoxus

Present Absent Kussmaul's sign

Often present Absent Pericardial knock

Absent May be present Electrical alternans

Absent Present Pericardial effusion

Present Absent Thickened pericardium

Often present Absent Pericardial calcification