Diseases of the Pericardium

Question 1

acute pericarditis

Answer 1

essentials of DX:

• ant pleuritic CP, worse supine than upright
• pericardial rub
• fever
• ESR elevation
• ECG reveals diffuse ST segment elevation w/ PR depression

etiology:

• acute (<2 weeks): infectious or d/t systemic diseases (AIS, uremia), neoplasm, radiation, drug toxicity, hemopericardium, postcardiac sx, contagious inflammatory pathologic process in myocardium or lung
• most cases, involved pericaridum and myocardium
• viral infections (especially infections with coxsackieviruses and echoviruses)
  
  • males under 50 yo
  • most common cause
  • lymph or hematogenous spread
• bacterial (rare; extension of pulmonary infections)
• CT disease ie SLE

clinical manifestations

• S:
  
  • substernal CP (pleuritic and postural) maybe radiating to neck, shoulders, back, and epigastrium
  • dyspnea
  • febrile
• O:
  
  • pericardial friction rub

management

• NSAIDS and ASA agents of first choice in uncomplicated
  
  • ASA first choice in post-MI
• colchicine can be used in severe cases, refractory cases, and recurrent
• complications = tamponade

Question 2

pericardial effusion

Answer 2

etiology:

• idiopathic
• infectious (viral, bacterial, TB)
• trauma (direct, indirect)
• neoplasms (breast, lung, lymphoma)
• diseases of contiguous strcutures
  
  • myocardial rupture, aortic dissection, hemopericardium post anticoag
• diseases of metabolism
  
  • uremia, hemorrhagic states, myxedema
• CT diseases
  
  • lupus, rheumatoid dz

clinical manifestations

• S: CP, dyspnea, cough
• O: pericardial friction rub

TX:

• small effusions = observations of JVP and testing for change in paradoxical pulse w/ serial echos
• pericardiocentesis in tamponade to drain

Question 3

Cardiac Tamponade

Answer 3

etiology

• hemodynamic compromise of diastolic filling and VR d/t compressive intrapericardial P from pericardial effusion =>
  
  • SV and arterial P drop
  • HR and VR rise
• smaller rapid effusions can cause tamponade
• shock and death may result
• equalization of diastolic P in all chambers (inc fluid, inc P in pericardial space)

clinical manifestations:

• S = CP, dyspnea, cough
• neck vein distention (elevated CVP)
  
  • d/t elevation of intrapericardial and thus intracardiac P
• very ill appearing
• tachycardia
• tachypnea
• muffled heart sounds (d/t fluid)
• PMI not palpable
• pulsus paradoxus (>10 mmHg BP dec w/ inspiration and inc w/ expiration)
  
  • since RV and LV share same pericardium, as RV enlarges w/ inspiratory filling, septal motion toward LV reduces LV filling and results in drop in SV and BP w/ inspiration)
• narrow pulse pressure, relatively preserved systolic BP
• pericardial friction rub may be present

ECG = elevated PR segment, ST elevation

TX:

• urgent pericardiocentesis is required
• always refer

Question 4

constrictive pericarditis

Answer 4

essentials of DX:

• R HF
• no fall or elevation in JVP w/ inspiration (Kussmaul sign)
• echo for evidence of septal bounce and reduced mitral inflow velocities w/ inspiration
• difficult to dx from restrictive cardiomyopathy
• cardiac cath may be necessary

etiology:

• idiopathic
• infectious
  
  • TB, viral
• CT disease
  
  • RA, SLE, scleroderma
• neoplasm
  
  • primary = mesothelioma, sarcoma
  • secondary = lung, breast, lymphoma
• trauma: penetrating, nonpenetrating
• radiation
• postpericardiotomy (coronary artery bypass)
• uremia

pathology

• inflammation can lead to thickened, fibrotic, adherent pericardium that restricts diastolic filling and produces chronically elevated venous pressures

clinical manifestations:

• S:
  
  • slow progressing dyspnea, fatigue, and weakness
  • chronic edema, hepatic congestion, ascites
    
    • ascites out of proportion to degree of peripheral edema
• O:
  
  • elevated JVP - apparent inc pulse wave at end of systole
  • Kussmaul sign - increase of JVP w/ inspiration
  • pleural effusion?
  • hepatomegaly
  • pericardial knock
• A:
  
  • ECG - low voltage
  • CXR = pericardial calcification, small heart, pleural effusion
  • Chest CT = thick pericardium

TX:

• diuretics initially (aggressive, d/t R HF, w/ loop diuretics, thiazides, and aldosterone antagonists esp w/ ascites)
• aquaphoresis may be of value
• sx pericardectomy when diuretics do not control sxs (removes pericardium b/n phrenic nerve pathways) + diuretics s/p procedure (high morbidity and mortality)