Dr. M. A. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin PERICARDITIS Dr. M. A. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin

Pericarditis INTRODUCTION — Pericardium is a fibroelastic sac made up of visceral and parietal layers separated by the pericardial cavity. In healthy individuals, the pericardial cavity contains 15 to 50 mL of an ultrafiltrate of plasma. Pericardial diseases are relatively common and present either as a manifestation of a systemic disorder or as isolated disease . Diseases of the pericardium present clinically in one of several ways: Acute and recurrent pericarditis Pericardial effusion without major hemodynamic compromise Cardiac tamponade Constrictive pericarditis Effusive-constrictive pericarditis

Acute pericarditis Pericardial effusion Acute pericarditis: refers to inflammation of the pericardial sac. The term myopericarditis is used for cases of acute pericarditis with myocardial inflammation. Acute pericarditis is an inflammation of the pericardium characterized by Chest pain Pericardial friction rub Serial ECG changes Manifestations include: Chest pain – Sharp and pleuritic, improved by sitting up and leaning forward Pericardial friction rub – A superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border Electrocardiogram (ECG) changes – New widespread ST elevation or PR depression Pericardial effusion

Chest pain — Pericarditis present with chest pain (>95% of cases). Sharp and stabbing (caused by the heart rubbing against the pericardium) May increase with coughing, swallowing, deep breathing or lying flat Can be relieved by sitting up and leaning forward Patient may need to bend over or hold to chest to breathe more comfortably Pericardial friction rub —  Highly specific for acute pericarditis. Generated by friction between the two inflamed layers of the pericardium.. Other symptoms include: Pain in the back, neck or left shoulder Difficulty breathing when lying down Anxiety or fatigue A dry cough

Electrocardiogram in acute pericarditis showing diffuse up-sloping ST segment elevations seen best here in leads I, II, aVL, and V4 to V6.

Cardiac auscultation supine and leaning forward Auscultation of the pericardium: To elicit pericardial rubs, the patient is invited to lean forward (A) or rest on elbows and knees (B). Both physical maneuvers increase the contact of visceral and parietal pericardium.

Characteristic Parameter Pericarditis Myocardial infarction Pain description Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain Crushing, pressure-like, heavy pain. Described as "elephant on the chest." Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw, or the left or arm, or does not radiate to back. Exertion Does not change the pain Can increase the pain Position Pain is worse in the supine position or upon inspiration (breathing in) Not positional Onset/duration Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours

Classification Pericarditis can be classified to the composition of the fluid Types of pericarditis include the following: Serous Purulent Fibrinous Caseous Hemorrhagic Acute vs. chronic Depending on the time and duration, pericarditis is divided into "acute" and "chronic" forms. Acute pericarditis is more common Chronic pericarditis, less common, a form of which is constrictive pericarditis. Clinically: Acute (<6 weeks) Subacute (6 weeks to 6 months) Chronic (>6 months)

Acute pericarditis Causes of pericarditis include: Idiopathic causes Infectious conditions, such as viral, bacterial, and tuberculous infections Inflammatory disorders, such as RA, SLE, scleroderma, and rheumatic fever Metabolic disorders, such as renal failure, hypothyroidism, and hypercholesterolemia Cardiovascular disorders, such as acute MI, Dressler syndrome, and aortic dissection Miscellaneous causes, such as iatrogenic, neoplasms, drugs, irradiation, cardiovascular procedures, and trauma

Laboratory and imaging findings Echocardiography Echocardiography is often normal in acute pericarditis unless associated with pericardial effusion. Finding of a pericardial effusion supports the diagnosis, the absence does not exclude it. CXR is only helpful with effusions >250mL. Small effusions (less than a few hundred milliliters) may present with a normal cardiac silhouette Lab tests may include CBC; serum electrolyte, blood urea nitrogen (BUN), and creatinine levels; lactate dehydrogenase (LDH), and serum glutamic-oxaloacetic transaminase (SGOT; AST) levels. Signs of inflammation: ESR and C-reactive protein (CRP) levels. Increases in serum biomarkers of myocardial injury such as cardiac troponin I or T  

Indications for pericardiocentesis and pericardial biopsy — Studies in patients with acute pericarditis have reported a low yield for diagnostic pericardiocentesis and pericardial biopsy. Some authors have advocated for a more extensive use of these techniques for diagnostic purposes. The majority of patients with uncomplicated acute pericarditis do not require invasive pericardial procedures. However, some high-risk patients may require pericardiocentesis for both therapeutic and diagnostic purposes

Large effusions refractory to medical treatment Pericardiocentesis  Pericardiocentesis —Pericardiocentesis or surgical drainage can serve both diagnostic and therapeutic purposes. Decisions for drainage are based upon: Echocardiographic characteristics of effusion(eg, size and composition) Clinical significance (eg, causing hemodynamic compromise). Symptomatic effusions and evidence of cardiac tamponade should undergo prompt pericardial drainage. Large effusions refractory to medical treatment Effusions that are small to moderate in size do not require drainage, unless a sample of the effusion is necessary for diagnostic purposes.

Indications for invasive workup in acute pericarditis Pericardiocentesis: Pericardial biopsy 1. Cardiac tamponade Relapsing cardiac tamponade 2. Moderate to large effusions refractory to medical therapy and with severe symptoms 2. Suspected bacterial or neoplastic pericarditis 3. Suspected bacterial or 3. Worsening pericarditis (despite medical therapy) without a specific diagnosis

Pericardial effusion Echocardigram

Diagnostic considerations: Costochondritis, or other noncardiac chest pain Pericarditis S/P renal transplantation, which may be due to uremia or infections (cytomegalovirus [CMV]. Liver disease has been noted in asymptomatic constrictive pericarditis. Large symptomatic pericardial effusions; 2/3 are potentially infections or neoplasms. Tuberculous pericarditis Tension pneumothorax may mimic cardiac tamponade Differentiating pericarditis from acute MI

Coronary Artery Vasospasm Esophageal Rupture Esophageal Spasm Differential diagnosis Angina Pectoris Aortic Dissection Aortic Stenosis Coronary Artery Vasospasm Esophageal Rupture Esophageal Spasm Esophagitis Gastritis, Acute Gastroesophageal Reflux Disease Myocardial Infarction Myocardial Ischemia Peptic Ulcer Disease Pulmonary Embolism

O2 and cardiac monitoring. Rule out life threatening: Management O2 and cardiac monitoring. Rule out life threatening: Myocardial infarction Aortic dissection. Evaluate for evidence of hemodynamic instability Consider whether further management is safe to continue on an OPD basis Avoid NSAIDs and corticosteroids in acute MI pericarditis, because they may interfere with ventricular healing, remodeling, or both

Poor prognostic factors: Myopericarditis Severe pericardial effusion Management Poor prognostic factors: Myopericarditis Severe pericardial effusion Cardiac tamponade Transfer to a hospital setting in which hemodialysis and cardiothoracic surgery are available Pericardiocentesis: People with effusions larger than 250 mL, effusions in which size increases Pericardiectomy is the most effective surgical procedure for managing large effusions

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