Pericardial DiseasePericardial Disease

Pericardium – 2 layers – visceralPericardium – 2 layers – visceral

- parietal- parietal

Acute pericarditis: symptoms and / or Acute pericarditis: symptoms and / or signs resulting from pericardial inflamation signs resulting from pericardial inflamation of no more than 1-2 weeks durationof no more than 1-2 weeks duration

HistoryHistory- chest pain- chest pain - almost always pleuretic, sharp- almost always pleuretic, sharp

- rapid onset- rapid onset- radiation – in the trapezius ridge- radiation – in the trapezius ridge- relieved by sitting foreward and worsened - relieved by sitting foreward and worsened

by by lying lying downdown- dyspnea, cough, hiccoughs- dyspnea, cough, hiccoughs- antecedent history of fever and / or symptoms suggesting a viral - antecedent history of fever and / or symptoms suggesting a viral syndromesyndrome

Differential diagnosisDifferential diagnosis- pneumonia - pneumonia ± pleurisy± pleurisy- pulmonari embolus / infarction- pulmonari embolus / infarction- pneumothorax- pneumothorax- costocondritis- costocondritis- gastroesophageal reflux disease- gastroesophageal reflux disease- myocardial ischemia- myocardial ischemia- aortis dissection- aortis dissection- herpes zoster pain- herpes zoster pain

Physical examinationPhysical examination- anxious, low grade fever- anxious, low grade fever- friction rub - 3 components: - friction rub - 3 components:

- ventricular systole- ventricular systole- early diastole filling- early diastole filling- atrial contraction- atrial contraction

- lower left sternal border- lower left sternal border- dynamic in time- dynamic in time

Laboratory testingLaboratory testingECG - diffuse ST segment elevation coved upwardECG - diffuse ST segment elevation coved upward

- PR segment depression- PR segment depression - Evolution – some patients ECG reverts to - Evolution – some patients ECG reverts to

normal over days or weeksnormal over days or weeks- in others – ST isoelectric – - in others – ST isoelectric –

depression + T inversion (in leads with upright QRS depression + T inversion (in leads with upright QRS complexes)complexes)

HemogramHemogram

- - ↑ WBC 11000-13000/mm³↑ WBC 11000-13000/mm³

Enzymes Enzymes – many patients – elevated CK-MB – many patients – elevated CK-MB and / or TnI (concomitant myocarditis)and / or TnI (concomitant myocarditis)

Chest X RayChest X Ray - usually normal- usually normal

- occasionally – small - occasionally – small pulmonary infiltration or pleural effusion (viral pulmonary infiltration or pleural effusion (viral infection)infection)

- bacterial – in conjunction with - bacterial – in conjunction with pneumoniapneumonia

Echo Echo – normal in acute idiopathic pericarditis– normal in acute idiopathic pericarditis

ManagementManagement

- AIP - self-limited disease- AIP - self-limited disease - NSAIDs – Ibuprofen 600-800mg x3/day with - NSAIDs – Ibuprofen 600-800mg x3/day with

discontinuation if pain is no longer present after 2 weeksdiscontinuation if pain is no longer present after 2 weeks - patients who respond inadequately to NSAIDs- patients who respond inadequately to NSAIDs

- analgetics and / or Colchicine or Prednisone- analgetics and / or Colchicine or Prednisone(Colchicine - loading 2-3 mg oral(Colchicine - loading 2-3 mg oral

- followed 1mg daily 10-14 days)- followed 1mg daily 10-14 days)(Prednisone 60mg daily – 2 days with (Prednisone 60mg daily – 2 days with

tapering to zero over a week)tapering to zero over a week)

Complication - effusionComplication - effusion

- tamponade- tamponade

- constrictive pericarditis- constrictive pericarditis

Relapsing - 15-30% after initial therapyRelapsing - 15-30% after initial therapy

- for an initial relapse - for an initial relapse

- 2 week course NSAIDs- 2 week course NSAIDs

- or Colchicine (nausea, - or Colchicine (nausea, diarrhea)diarrhea)

Reccurent pericardial painReccurent pericardial pain

- Azathioprine, Cyclophosphamide- Azathioprine, Cyclophosphamide

- Human Immunoglobulines- Human Immunoglobulines

- Pericardectomy - Pericardectomy

Etiology - idiopathic pericarditisEtiology - idiopathic pericarditis - infection- infection - neoplasm- neoplasm - autoimmune- autoimmune - inflammatory process- inflammatory process - patients with severe circulatory congestion- patients with severe circulatory congestion - trauma- trauma - aortic dissection- aortic dissection

PathophysiologyPathophysiology- inflammatory and/or infectious process affecting the - inflammatory and/or infectious process affecting the

pericardium pericardium → effusion→ effusion- as fluid accumulates – left and right-sided atrial and - as fluid accumulates – left and right-sided atrial and

ventricular diastolic pressure rise and in severe tamponade equalise ventricular diastolic pressure rise and in severe tamponade equalise at a pressure similar to that in the pericardiumat a pressure similar to that in the pericardium

- paradoxical pulse = abnormally large decline in systolic - paradoxical pulse = abnormally large decline in systolic arterial pressure during inspirationarterial pressure during inspiration

Pericardial effusion and tamponadePericardial effusion and tamponade

Clinical presentationClinical presentation- pericardial pain- pericardial pain- tamponade - dyspnea- tamponade - dyspnea

- more confortable sitting - more confortable sitting forewardforeward

Physical Exam Physical Exam - without tamponade – normal- without tamponade – normal

- with tamponade – Beck triade:- with tamponade – Beck triade: - hypotension- hypotension

- muffled heart sound- muffled heart sound - elevated jugular - elevated jugular

pressurepressureECG - ECG - ↓ voltage (non-specific), electrical alternans ↓ voltage (non-specific), electrical alternans (specific but insensitive)(specific but insensitive)X Ray – cardiac silhouette normal until effusion is X Ray – cardiac silhouette normal until effusion is moderatemoderate

EchocardiographyEchocardiography

- effusion- effusion

- tamponade - tamponade

- early diastolic collapse of the right - early diastolic collapse of the right ventricleventricle

- collapse of the right atrium (in - collapse of the right atrium (in ventricular diastole)ventricular diastole)

- exaggerated respiratory variation - exaggerated respiratory variation - inspiratory increase on the right- inspiratory increase on the right

- decrease of the left- decrease of the left

CT, MRI CT, MRI – detailed quantitation and regional / – detailed quantitation and regional / spatial localizationspatial localization

ManagementManagement a)a) Effusion without actual or threatened tamponadeEffusion without actual or threatened tamponade

- management can be more leisurely- management can be more leisurely- pericardiocentesis need only be undertaken for - pericardiocentesis need only be undertaken for

diagnosis purposes and is usually not requireddiagnosis purposes and is usually not required- NSAIDs or Colchicine- NSAIDs or Colchicine

b)b) Effusions with actual or threatened tamponade Effusions with actual or threatened tamponade- medical emergency- medical emergency- hemodynamic and echo monitoring- hemodynamic and echo monitoring- treatment individualized- treatment individualized

- acute, idiopathic, mild tamponade- acute, idiopathic, mild tamponade - can be treated NSAID and/or Colchicine- can be treated NSAID and/or Colchicine - autoimmune disease- autoimmune disease - same way and/or corticosteroids- same way and/or corticosteroids - possible bacterial infections, effusions - possible bacterial infections, effusions ≤ moderate≤ moderate - in same cases- initial conservative management- in same cases- initial conservative management - for most patients- urgent or emergent - for most patients- urgent or emergent

pericardiocentesispericardiocentesis

Constrictive pericarditisConstrictive pericarditis

CP is the end stage of on inflammatory procesesCP is the end stage of on inflammatory procesesEtiologyEtiology- idiopathic, irradiation, postsurgical, infections, - idiopathic, irradiation, postsurgical, infections, neoplasm, autoimmune (connective tissue) disorders neoplasm, autoimmune (connective tissue) disorders uremia, posttrauma,sarcoid, methysergide therapy, uremia, posttrauma,sarcoid, methysergide therapy, implantable defibrillator patches, tuberculosisimplantable defibrillator patches, tuberculosisPathophysiologyPathophysiology

- markedly restricted filling of the heart- markedly restricted filling of the heart - almost all ventricular filling occurs early in diastole- almost all ventricular filling occurs early in diastole - systemic venous congestion- hepatic congestion, - systemic venous congestion- hepatic congestion,

peripheral edema, ascites, anasarcaperipheral edema, ascites, anasarca - - ↓ CO- fatigue, muscle wasting, weight loss↓ CO- fatigue, muscle wasting, weight loss

Clinical presentationClinical presentation- signs and symptoms of predominantly right heart failuresigns and symptoms of predominantly right heart failure- ↑ ↑ pulmonary venous pressure- pulmonary venous pressure- exertional dyspneea, exertional dyspneea,

cough, orthopneacough, orthopnea- atrial fibrillationatrial fibrillation- Fatigue, cachexiaFatigue, cachexia

Physical findingsPhysical findings - elevated jugular venous pressure- elevated jugular venous pressure - Kusmaul sign- inspiratory increase in systemic venous - Kusmaul sign- inspiratory increase in systemic venous

pressurepressure - pericardial Knock- early diastolic sound best heard at - pericardial Knock- early diastolic sound best heard at

left sternal beorder and/or the cardiac apexleft sternal beorder and/or the cardiac apex - coresponds to the early, abrupt - coresponds to the early, abrupt

cessation of ventricular fillingcessation of ventricular filling - hepatomegaly, jaundice, palmar erythema- hepatomegaly, jaundice, palmar erythema

ECGECG- no specific ECG findings- no specific ECG findingsChest RxChest Rx - cardiac silhouette can be enlarged - cardiac silhouette can be enlarged - pericardial calcification - pericardial calcificationEcho-Echo- pericardial thickening pericardial thickening - abrupt dissplacement of IVS during early diastole - abrupt dissplacement of IVS during early diastole - exaggerated septal shifting - exaggerated septal shiftingCatheterizationCatheterization - RA, Rv diastolic, PCW, LV diastolic pressure are elevated - RA, Rv diastolic, PCW, LV diastolic pressure are elevated and equaland equal - marked diastolic dip followed by a plateau (square root - marked diastolic dip followed by a plateau (square root sign) sign) - PASP - PASP ~ 35-45 mmHg~ 35-45 mmHgCT, MRI-CT, MRI- detected images of pericardium detected images of pericardium - absence of pericardial thickening argues against the - absence of pericardial thickening argues against the diagnosis of constriction diagnosis of constriction

ManagementManagement

Surgical pericardiectomySurgical pericardiectomy

Diets, salt restrictionDiets, salt restriction

ß blockers, calcium blockers (should be ß blockers, calcium blockers (should be avoided) the rate shouldn’t be allowed to avoided) the rate shouldn’t be allowed to drop below 80-90 beats/mindrop below 80-90 beats/min

Atrial fibrillation- digoxinAtrial fibrillation- digoxin