Pericarditis and Pericardial effusion

Dr Muxyi

Learning objectives:at the end of this lesson the student will be able to:• • 1. Define Pericarditis.• • 2. List the etiologies of Pericarditis.• • 3. Describe the different types of Pericarditis.• • 4. Understand the pathophysiology of Pericarditis.• • 5. Identify the clinical manifestation of Pericarditis.• • 6. Identity acute and chronic complications of Pericarditis.• • 7. Understand the diagnostic approach of Pericarditis.• • 8. Understand the principle of management of Pericarditis.•

Definition:

Pericarditis is an inflammation of the pericardium surrounding the heart.

Percarditis and cardiac tamponade are clinical problems involving the potential space surrounding the heart or pericardium.

Pericarditis is one cause of fluid accumulation in this potential space and cardiac tamponade is the hemodynamic result of fluid accumulation.

Pathophysiology

• The pericardium consists of an outer fibrous layer (parietal pericardium) and an inner serous layer (visceral pericardium).

• Normally the two layers are separated by a small quantity of fluid (15-50 ml).The pericardium serves as a protective barrier from the spread of infection or inflammation from adjacent structures. It also prevents sudden dilatation of the cardiac chambers during exercise and hypervolumia. It restricts the anatomic position of the heart and minimizes friction with the surrounding structures.

• Approximately 120 cc of additional fluid can accumulate in the pericardium without an increase in pressure.

• Further fluid accumulation can result in marked increases in pericardial pressure, eliciting decreased cardiac output and hypotension (cardiac tamponade). The rapidity of fluid accumulation influences the hemodynamic effect.

Clinical classification Etiologic Classification

I. Acute pericarditis (<6 weeks)a. Fibrinous

b. Effusive (serous or sanguineous)

II. Subacute pericarditis (6 weeks to 6 months)

A .Effusive-constrictive

B. Constrictive

III. Chronic pericarditis (over 6 months)

a. Constrictive b.

Effusivec. Adhesive (nonconstrictive)

I. Infectious Pericarditisa. Viralb. Pyogenic

c. Tuberculous

d. FungalII. Noninfectious Pericarditis

a. Uremia

b. Acute myocardial infraction c.

Neoplasmd. Idiopathic

III. Hypersensitivity/autoimmunea. Rheumatic fever

b. Rheumatoid arthritis c.

SLEd. Posttraumatic

Table –III-8-1. Classification of Pericarditis

TB pericarditis is quite common in HIV positive patients.

Clinical features

Pericarditis• The most common symptom of acute pericarditis is

precordial or retrosternal chest pain, usually described as sharp or stabbing.

o Pain may be of sudden or gradual onset and may radiate to the back (left trapezial ridge), neck, left shoulder, or arm.

o Movement or inspiration may aggravate the pain.o Pain may be most severe when the patient is supine

and can be relieved when the patient leans forward while sitting.

Commonly associated symptoms include low-grade intermittent fever, dyspnea, cough, and dysphagia.

In tuberculosis pericarditis, fever, night sweats, and weight loss are commonly noted (80%).

Some patients may present with acute abdominal pain.

C/F of Cardiac tamponade

• Patients may present subacutely with symptoms of anxiety, dyspnea, orthopnea, fatigue, or altered mental status.

• Patients may have a history of medical illnesses associated with pericardial involvement, particularly end-stage renal disease (ESRD).

• Traumatic tamponade may present with acute dyspnea or altered mental status.

• A waxing and waning clinical picture may be present in intermittently decompressing tamponade.

Physical findings: Pericarditis

• The classic sign of acute pericarditis is pericardial friction rub, which is scratchy,leathery sound heard during both systole and diastole. It is best, heard at the lower left sternal border or apex when the patient is positioned sitting forward.

Friction rub may be transient from one hour to the next and is present in approximately 50% of cases.

A friction rub may be distinguished from a cardiac murmur by

its changing character from heartbeat to heartbeat and patient position changes. A friction rub is closer to the ear on auscultation than a murmur.

Fever: usually is low grade, but it may occasionally reach 390 C.

Cardiac arrhythmias: Premature atrial and ventricular contractions occasionally are present.

Tachypnea and dyspnea: Dyspnea is a frequent complaint and it may be severe with myocarditis, pericarditis, and tamponade.

Ewart sign (dullness and bronchial breathing between the tip of the left scapula and the vertebral column)

Hepatomegally and ascites may be found.

Cardiac tamponade

As the volume of pericardial fluid increases, the capacity of the atria and ventricles to fill is mechanically compromised, leading to reduced stroke volume and tamponade. It is influenced by volume and rate of accumulation

Beck triad (jugular venous distention, hypotension, and muffled heart sounds) Neck vein distension is a common finding: but Kussmaul’s sign is absent.

Hypotension to the extent of shock: may occur when the cardiac stroke volume is significantly reduced and tissue perfusion is compromised

Pulsus paradoxus: abnormal fall in blood pressure by more than 10 mm Hg during inspiration.

Narrow pulse pressure: indicates reduced left ventricular stroke volume.

CyanosisVarying degrees of altered consciousness

Diagnostic workup

Laboratory studies:1. CBC with differential2. Elevated erythrocyte sedimentation rate

(ESR)3. HIV testing4. Antinuclear antibody, rheumatoid factor

Imaging Studies:

Chest radiography: A bottle–shaped heart can be seen with excessive pericardial fluid accumulation.

In cardiac tamponade (or large effusions), the chest x-ray may demonstrate an enlarged cardiac silhouette after 200-250 ml of fluid accumulation. This occurs in patients with slow fluid accumulation, compared to a normal cardiac silhouette seen in patients with rapid accumulation and tamponade. Thus, the chronicity of the effusion may be suggested by the presence of a huge cardiac silhouette.

ECHO: minimal pericardial effusion in pericarditis and significant pericardial effusion in Chonic pericarditis or Cardiac tamponade.

ECG : Acute pericarditis: diffuse ST segment elevation without reciprocal

ST segment depression and depression of PR segment is unique to acute pericarditis reported in up to 80% of viral pericarditis cases..

Cardiac tamponade or massive effusion: electrical alternans is pathognomonic of cardiac tamponade and is characterized by alternating levels of ECG voltage of the P wave, QRS complex, and T waves. This is a result of the heart swinging in a large effusion. Low voltage of ECG.

Treatment

1. Acute Pericarditis:Treating pain and inflammation:• Nonsteroidal anti-inflammatory drugs (NSAID):

ASA, Indomethacine and Ibuprofen are effective in reducing the inflammation and reliving the chest pain.

• Steroid therapy: intractable cases of pericarditis that fail to respond to NSAID.

Specific therapy

should be directed towards the cause of pericarditis.

E.g. Patients with TB pericarditis should be treated with ant TB along with steroid

2. Cardiac tamponadePatients with evidence of cardiac tamponade

need emergency pericadiocentesis i.e. removal of fluid from pericardial sac.

Complications of Pericarditis:

1. Recurrence : pericarditis may recur in 15-32% of patients

2. Cardiac tamponade3. Chronic constrictive pericarditis4. Cardiac perforation at time of pericardiocentesis5. Bronchopericardial fistula: This was noted as a

complication of multi–drug-resistant TB in a patient with HIV.

• Prognosis: The prognosis of pericarditis depends upon the etiology of the pericardial infection or inflammation as well as the presence of a pericardial effusion and/or tamponade.

Thanks