Pericardial disease

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Pericardial disease:

Pericardial disease Cardiology Department


Pericardium Visceral / serous Direct contact with epicardium (ST elev ) single layer mesothelial cells Parietal / fibrous mesothelial and fibrous layer

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Acute pericarditis Pericardial effusion Cardiac tamponade Constrictive pericarditis

Acute pericarditis :

Acute pericarditis Inflammation of the pericardium

Etiology – Acute Pericarditis:

Etiology – Acute Pericarditis Infectious Viral : Coxsackie, Echo, EBV, Influenza, HIV Bacterial: TB, staph, hemophillus , pneumococcal, salmonella Fungal/other: histo / blasto / coccidio , rickettsia R heumatologi c SLE, Sarcoid , RA, Dermatomyositis , Ankylosing Spondylitis , Scleroderma, PAN Neoplastic Primary: angiosarcoma , mesothelioma Metastatic: breast, lung, lymphoma, melanoma, leukemia Immunologic Celiac sprue , Inflammatory Bowel Disease Drug Hydralizine , Procainamide Other MI, Dressler’s, Post Pericardiotomy , Chest Trauma, Aortic dissection Uremic, Post Radiation IDIOPATHIC


Diagnosis Chest pain : anterior chest, sudden onset, pleuritic ; may decrease in intensity when leans forward, may radiate to one or both trapezius ridges Supporting symptoms: Fever Flu like symptoms Pericardial friction rub: most specific, heard best at LSB


Investigations EKG changes : New widespread ST elevation or PR depression

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Constrictive Pericarditis can be “transient” – 10% may have transient sxs 1 s month , resolves by 3 months Recurrent Pericarditis (20-25%) Rx – NSAIDS/ Colchicine +/- steroids


ECG Generalized ST elevation with concave up ST/T ratio in lead V6 >0.25 No reciprocal changes PR depression DDx : Acute MI Early Repolarization Myocarditis

ECG changes Stages:

ECG changes Stages Stage I first few days  2 weeks ST elev, PR depression up to 50% of pt with sxs/rub do NOT have/evolve stage I 1 Stage II last days  weeks ST returns to baseline, flat T Stage III after 2-3 weeks, lasts several weeks T wave inversion Stage IV lasts up to several months gradual resolution of T wave changes 1 Spodick DH, Pericardial Disease. Braunwauld 6 th

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Cardiac biomarkers : Normal CXR PA : usually normal cardiac size, cardiomegaly only in the presence of PE ECHO : absence of pericardial effusion does not exclude diagnosis of pericarditis

Other Tests:

Other Tests ANA HIV Blood cultures Viral studies b/c yield is low and management is not altered


Treatment NSAIDS ASA 650 q 3-4hr Ibuprofen 300-600 q 6-8 hrs x 1-4days Steroids if no response after 48hr NSAID use concurrent NSAID Colchicine useful in recurrent pericarditis 1 Adler Y, et al. Circulation, 1998 June 2


Complications Pericardial Effusion/Tamponade Constrictive Pericarditis can be “ transient” Recurrent Pericarditis Rx – NSAIDS/ Colchicine +/- steroids

Pericardial Effusion and Cardiac Tamponade:

Pericardial Effusion and Cardiac Tamponade

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Etiology Physiology - comparison with constrictive pericarditis Types of tamponade Diagnosis - clinical presentation, physical exam, EKG, CXR, echo Treatment Tamponade


Etiology Infectious Viral ( coxsackie B, echovirus, influenza) Bacterial Others: TB, fungal, toxoplasmosis Neoplastic Uremic Trauma / cardiac surgery / aortic dissection / cardiac procedures Radiation Connective tissue disease (RA, SLE, scleroderma) Myocardial ischemia / infarct Myxedema Idiopathic


Physiology Exaggerated ventricular interaction During inspiration  g reater RV inflow and outflow and concurrent decrease in LV size, outflow tract flow velocity profile and mitral valve inflow During expiration  LV filling and LV outflow augmented at the expense of reduced RV volume and Doppler flow velocities


Physiology Normal pericardium Increasing pericardial pressure Increasing filling pressures RVEDP = LVEDP Equalization of diastolic pressures

Clinical Presentation:

Clinical Presentation Tachypnea and exertional dyspnea  rest air hunger Weakness Presyncope Dysphagia Cough Anorexia Chest pain

Physical Exam Findings:

Physical Exam Findings Tachycardia Hypotension  shock Elevated JVP with blunted y descent Muffled heart sounds Pulsus paradoxus Pericardial rub

Pulsus paradoxus:

Pulsus paradoxus Defined as an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration . The normal fall in pressure is less than 10 mmHg . When the drop is more than 10mm Hg, it is referred to as pulsus paradoxus

Pulsus paradoxus:

Pulsus paradoxus Inflate cuff until no sounds (as is normally done when taking a BP) slowly decrease cuff pressure until systolic sounds are first heard during expiration but not during inspiration, (note this reading), slowly continue decreasing the cuff pressure until sounds are heard throughout the respiratory cycle, (inspiration and expiration)(note this second reading). If the pressure difference between the two readings is >10mmHg, it can be classified as pulsus paradoxus .

EKG tamponade:

EKG tamponade


Diagnosis EKG – low voltage, sinus tach, PR depression, electrical alternans

Chest X-ray:

Chest X-ray

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CXR enlarge cardiac silhouette, water bottle shaped heart


ECHO 2D and M-mode Pericardial effusion Early diastolic collapse of the right ventricular free wall Late diastolic compression/collapse of the right atrium Swinging of the heart in its sac Doppler

Right Heart Catheterization :

Right Heart Catheterization If patient is stable and diagnosis is in doubt In tamponade, near equalization (within 5 mm Hg) of the right atrial , right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure Rt atrial pressure tracings show absent systolic y descent


Treatment Oxygen Volume expansion with blood, plasma, or saline to maintain adequate intravascular volume Bed rest with leg elevation This may help increase venous return. Inotropic drugs (i.e. dobutamine ) Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.



Constrictive pericarditis:

Constrictive pericarditis

Constrictive pericarditis:

Constrictive pericarditis caused by fibrosis and calcification of the pericardium and consequent loss of the normal elasticity of the pericardial sac that inhibit diastolic filling of the hear

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Most common etiologies: TB Idiopathic Post pericarditis of any etiology Radiation

Clinical features:

Clinical features Fatigue, SOB hypotension , tachycardia Elevated JVP Kausmaal’s sign Pericardial “knock” Ascites , edema

Jugular venous pressure patterns:

Jugular venous pressure patterns



CT chest :

CT chest

ventricular diastolic pressures:

ventricular diastolic pressures

Treatment :

Treatment Salt and fluid restriction Diuretics pericardiectomy

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