Pericardial Diseases Flashcards
Pericardium is composed of …
Two layers:
- Visceral pericardium
- Parietal pericardium
Describe how the visceral pericardium is composed:
- Membrane composed of single layer mesothelial cells
- Similar to pleural and peritoneal cavity
- Adherent to the epicardial surface of the heart
Describe how the parietal pericardium is composed:
- Fibrous layer 2mm in thickness
- Contains collagen and elastic fibers
-
Collagen:
- Low levels of stretch ⇒ Wavy bundles
- High levels of stretch ⇒ Streight bundles
- Reflects the mechanical characteristics of the pericardial tissue
The visceral pericardium reflects back near the origin of the _____ ______ and becomes the ______ ________.
- How much serous fluid is in the pericardial space in a healthy individual?
The visceral pericardium reflects back near the origin of the great vessels and becomes the parietal pericardium.
-
Pericardial space
- Contains ≈ 15 - 50ml serous fluid in a healthy individual
What stabilizes the pericardium?
Stabilized by ligamentous attachements
- Diaphragm
- Sternum
- Spine
Phrenic nerves are enveloped by _______ __________.
- What happens if the phrenic nerve is irritated?
Phrenic nerves are enveloped by parietal pericardium.
- Phrenic nerve irritation ⇒ hiccups
What are the major functions of the pericardium?
- Maintains heart position
- Lubrication of visceral and parietal layers
- Barrier to infection
-
Prostaglandin secretion
- Modulation of coronary vascular tone
- Restraining effect on cardiac volume
- What is the restraining effect of the pericardium?
- How does the pericardium respond to increased cardiac volumes?
-
Restraining effect on cardiac volume
- Mechanical properties of pericardial tissue
- Small reserve volume
- Tensile strength similar to rubber
- Normal cardiac volume
- More elastic ⇒ stretches easily
-
When there is increased cardiac volumes:
- Pericardial tissue becomes stiff ⇒ resistant to further stretch
How is the Pericardial Pressure Volume Curve practically significant in pericardial effusions?
Practical significance in pericardial effusions
- Once critical volume of effusion is reached small additional amounts ⇒ large increase of intrapericardial pressure
- Removal of small amount of fluid ⇒ significant improvement of pressure
Acute vs chronic cardiac dilatation
- Chronic cardiac dilatation results in adaptations to accomodate increased cardiac volumes
- Pericardial growth occurs in response to chronic stretch
- Pressure volume curve shifts to the right with decreased slope
- Slowly accumulating pericardial effusions can become very large before becoming symptomatic (Hypothyroidism)
What is the major cause of acute pericarditis?
-
Majority (80-90%) of cases “Idiopathic”
- No specific etiology identified with routine diagnostic testing
- Most acute “Idiopathic” cases are assumed to be viral in etiology
- Routine testing for specific viral agents not done
What are other causes of acute pericarditis?
- Infectious
- Viral (Echo/Coxsackie/Adenovirus, CMV, HIV)
- Bacterial(Pneumococcus/Strep/staph/mycoplasma/haemophilus)
- Myobacteria (MT/MAI)
- Radiation (Acute and chronic)
- Blunt and penetrating trauma
- Connective tissue disorders
- SLE, RA, Systemic sclerosis
- Post MI, and Dressler syndrome
What is the classic presentation of acute pericarditis?
-
Chest pain
- Almost always present
- Usually moderate to severe in intensity
- Better sitting forward, worse when lying down
- Sharp, pleuritic like
- Substernal, epigastric, left chest, trapezius muscle area (specific for pericarditis)
- Can be associated with dyspnea, cough, hiccups, fever
Differential diagnosis of CP in pericarditis:
- Pneumonia with pleurisy (Pleuro-pericarditis)
- PE with infarction
- Costochondritis
- GERD
- Intraabdominal processes
- Aortic dissection
- Pneumothorax
- Herpes Zoster (Before skin lesions)
- Myocardial ischemia/infarction
- Presenting manifestation of clinically silent MI
What can be found upon physical examination on a patient with acute pericarditis?
- Uncomplicated acute pericarditis
- Fever, tachycardia, anxiety (Not always present)
- Pericardial friction rub
Describe the pericardial friction rub in acute pericarditis:
- Contact between parietal and visceral
- Usually three components
- Ventricular Systole, diastole, atrial contraction
- Best heard at left LSB, w/ patient leaning forward
- Dynamic (Similar to ECG findings)
- Disappearing/returning over short periods of time
- Frequently exam when suspecting pericarditis without audible rub
- One or two component rub can represent mumurs (Use Caution)
What are the ECG findings in acute pericarditis?
- ECG changes are dynamic (Like rub)
-
ST segment elevation
- Diffuse (Not in leads AVR,V1)
- Occasionally focal (Trauma and post-op)
- ST segment concave
- No reciprocal changes
- Upright T waves
-
PR depression (Elevation in AVR)
- PR depression may be only ECG finding
What are additional ECG findings in acute pericariditis?
- Low voltage QRS
- Electrical alternans
- Secondary to pericardial effusion
What are some potential lab findings in acute pericarditis?
-
Idiopathic “Viral” pericarditis
- Mild elevation of WBC count with lymphocytosis
- Mild elevation of ESR
-
Consider Secondary Etiologies:
- Significant WBC elevation with left shift
- Anemia, elevated ESR (Connective tissue disorders)
- Elevated ESR (Connective tissue disorders, TB)
What can be found on CxR in complicated acute pericarditis?
Abnormal CXR findings consided 2ry disorders
- Pleural effusions
- Infilrates
- Mass lesions
- CHF
Why is an echocardiogram used in a patient with acute pericarditis?
- Not required for diagnosis and management of idiopathic pericarditis
- Small otherwise clinically silent effusion not uncommon
- Large effusion consider secondary disorder
- LV function assessment in pt with myocarditis
- Check for WMA if ischemia/MI suspected
What is used to treat “idiopathic” acute pericarditis?
- Uneventful recovery in 70% - 90% of patients
- Treatment with NSAIDS (Post MI use aspirin)
-
Colchicine
- With NSAIDS
- Alternative to NSAIDS
- Decreased incidence of recurrent pericarditis
- Discontinuation rate 10%-15% (GI side effects)
-
Steroids
- Rapid response to treatment
- Corticosteroids may encourage relapses (Avoid if possible)
What does colchicine act on?
-
Inhibits the process of microtubule self-assembly
- This takes place either in the mitotic spindle or in the interphase stage
- Inhibits movement of intercellular granules and the secretion of various substances in leucocytes
- Significant anti-inflammatory action
- Colchicine has preferential concentration in leukocytes
- Peak concentration of colchicine may be 16 times the peak concentration in plasma
What was the conclusion of the COPE trial?
Conclusion of the COPE trial:
-
Colchicine + coventional therapy led to clinically important and statistically significant benefit over conventional treatment
- decreasing the recurrence rate in patients with a first episode of acute pericarditis
- Corticosteroid therapy given in the index of attack can favor the occurence of recurrences
How is acute pericarditis diagnosed?
Two of the following criteria:
- Typical chest pain (sharp and pleuritic, improved by sittng up and leaning forward);
- Pericardial friction rub
- Suggestive changes of on ECG (widespread ST-segment elevation or PR depression)
- New or worsening pericardial effusion
What is “incessant” pericarditis?
diagnosis of incessant pericarditis:
- patients with persistent pericarditis
or
- those with symptom-free intervals of less than 6 weeks duration
**Specific Causes of Pericardial Disease: **
Noninflammatory Conditions
-
Hydropericardium is an accumulation of serous transudate in the pericardial space
- Associated with congestive heart failure, hyponatremia or chronic kidney or liver diseases;
-
Hemopericardium is an accumulation of blood in the pericardiac sac
- Trauma of either the heart or aorta
- Myocardial rupture after acute MI
How is HIV involved in pericardial disease?
- More common pre-HAART
- 20% of HIV patients develop pericardial involvement
- Pericardial effusion most common cardiac manifestation of HIV infection
- Seen in more advanced stages of the disease
- Presence of pericardial effusion associated with X9 greater 6 month mortality (independed of CD4 count)
- Most effusions are small, asymptomatic, and idiopathic
- Generalized sero-effusive process (“Capillary leak” syndrome)
-
Large effusions usually secondary to:
- Infection (MT, MAI, CMV, Cryptococcus)
- Neoplasm (Kaposi sarcoma, lymphomas)
-
Treatment
- Identification of underlying etiology
