Pericardial Disease

Question 1

Pericarditis

Answer 1

Defined as inflammation of the pericardial sac. It can compromise cardiac output via tamponade or constrictive pericarditis.

Most commonly idiopathic, although known etiologies include viral infection, TB, SLE, uremia, drugs, radiation, and neoplasms.

May also occur after MI (within days or as delayed autoimmune process like Dressler’s) or open heart surgery

Question 2

Causes of pericarditis

Answer 2

CARDIAC RIND

Collagen vascular disease
Aortic dissection
Radiation
Drugs
Infectious
Acute renal failure
Cardiac (MI)

Rheumatic fever
Injury
Neoplasms
Dressler’s

Question 3

History and physical for pericarditis

Answer 3

1) May present with pleuritic chest pain, dyspnea, cough and fever
2) Chest pain tends to worsen in the supine position and with inspiration
3) Exam may reveal a pericardial friction rub. Elevated JVP and pulsus paradoxus can be present with tamponade

Question 4

Diagnosis of pericarditis

Answer 4

1) CXR, ECG, and echo to rule out MI and pneumonia
2) ECG changes include diffuse ST elevation and PR segment depression followed by T wave inversions
3) pericardial thickening or effusion may be evident on echo

Question 5

Treatment of pericarditis

Answer 5

1) Address underlying cause (corticosteroids/immunosuppressants for SLE, dialysis for uremia) or symptoms (ASA for post-MI pericarditis, ASA/NSAIDs for viral pericarditis). Avoid steroids within a few days after MI as they can predispose to ventricular wall rupture
2) Pericardial effusions without symptoms can be monitored, but evidence of tamponade requires pericardiocentesis with continuous drainage as needed

Question 6

Cardiac tamponade

Answer 6

Defined as excess fluid in pericardial sac, leading to compromised ventricular filling and reduced cardiac output. The rate of fluid formation is more important than the size of the effusion.

Risk factors include: pericarditis, malignancy, SLE, TB, trauma (commonly stab wounds medial to L nipple)

Question 7

History and physical of cardiac tamponade

Answer 7

1) Presents with fatigue, dyspnea, anxiety, tachycardia and tachypnea that can rapidly progress to shock and death
2) Exam of a patient with acute tamponade may reveal Beck’s triad (hypotension, distant heart sounds, JVD), a narrow pulse pressure, pulsus paradoxus, and Kussmaul’s sign (JVD on inspiration)

Question 8

Diagnosis of cardiac tamponade

Answer 8

1) Echo shows R atrial and RV diastolic collapse
2) CXR may show enlarged, globular, water-bottle-shaped heart with a large effusion
3) If present on ECG, electrical alternans is diagnostic of a large pericardial effusion

Question 9

Treatment of cardiac tamponade

Answer 9

1) Aggressive volume expansion with IVFs
2) Urgent pericardiocentesis (aspirate will be nonclotting blood)
3) Decompensation may warrant pericardial window