Pericardial Disease 10/2012 medslides.com
Pericardial Disease Acute Pericarditis Chronic Relapsing Pericarditis Constrictive Pericarditis Cardiac Tamponade Localized and Low Pressure Tamponade Restrictive Cardiomyopathy 9/98 medslides.com
Pericardial Anatomy Two major components serosa (viceral pericardium) mesothelial monolayer facilitate fluid and ion exchange fibroa (parietal pericardium) fibrocollagenous tissue Pericardial Fluid 15 - 50 ml of clear plasma ultrafiltrate Ligamentous attachments to the sternum, vertebral column, diaphragm 9/98 medslides.com
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Pericardial Physiology not needed to sustain life physiologic functions limit cardiac dilatation maintain normal ventricular compliance reduce friction to cardiac movement barrier to inflammation limit cardiac displacement 9/98 medslides.com
Pericardial Inflammation pathogenesis Contiguous spread lungs, pleura, mediastinal lymph nodes, myocardium, aorta, esophagus, liver Hematogenous spread septicemia, toxins, neoplasm, metabolic Lymphangetic spread Traumatic or irradiation 9/98 medslides.com
9/98 medslides.com
Pericardial Inflammation pathology inflammation provokes a fibrinous exudate with or without serous effusion the normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac can cause pericardial scarring with adhesions and fibrosis 9/98 medslides.com
PERICARDITIS 9/98 medslides.com
Acute Pericarditis common causes Outpatient setting usually idiopathic probably due to viral infections Coxsackie A and B (highly cardiotropic) are the most common viral cause of pericarditis and myocarditis Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV 9/98 medslides.com
Acute Pericarditis common causes Inpatient setting T = Trauma, TUMOR U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine, procain) O = Other infections (bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder Radiation 9/98 medslides.com
Acute Pericarditis Diagnostic Clues History sudden onset of anterior chest pain that is pleuritic and substernal Physical exam presence of two- or three-component rub ECG most important laboratory clue 9/98 medslides.com
Chest Pain History pericarditis vs infarction Common characteristics retrosternl or precordial with raditaion to the neck, back, left shoulder or arm Special characteristics (pericarditis) more likely to be sharp and pleuritic with coughing, inspiration, swallowing worse by lying supine, relieved by sitting and leaning forward 9/98 medslides.com
Heart Murmurs of Pericarditis Pericardial friction rub is pathognomic for pericarditis scratching or grating sound Classically three components: presystolic rub during atrial filling ventricular systolic rub (loudest) ventricular diastolic rub (after A2P2) 9/98 medslides.com
Acute Pericarditis ECG features ST-segment elevation reflecting epicardial inflammation leads I, II, aVL, and V3-V6 lead aVR usually shows ST depression ST concave upward ST in AMI concave downward like a “dome” PR segment depression (early stage) T-wave inversion occurs after the ST returns to baseline 9/98 medslides.com
9/98 medslides.com
9/98 medslides.com
9/98 medslides.com
Acute Pericarditis Management Treat underlying cause Analgesic agents codeine 15-30 mg q 4-6 hr Anti-inflmmatory agents ASA 648 mg q 3-4 hrs NSAID (indomethacin 25-50 mg qid) Corticosteroids are symptomatically effective , but preferably avoided 9/98 medslides.com
Chronic Relapsing Pericarditis occurs in a small % of patients with acute idiopathic pericarditis steroid dependency requiring gradual tapering over 3-12 months; NSAIDs, analgesics, and colchicine may be beneficial pericardiectomy for relief of symptoms is not always effective 9/98 medslides.com
Dressler’s Syndrome Described by Dressler in 1956 fever, pericarditis, pleuritis (typically with a low grade fever and a pericardial friction rub) occurs in the first few days to several weeks following MI or heart surgery incidence of 6-25% treat with high-dose aspirin 9/98 medslides.com
Acute Pericarditis Differential Diagnosis Acute myocardial infarction Pulmonary embolism Pneumonia Aortic dissection 9/98 medslides.com
Case Study 1 A 56-year-old man develops recurrent chest discomfort 5 days after an anterior myocardial infarction, which was managed initially with tissue plasminogen activator. The pain is sharp and positional, radiating toward both clavicles. It is different from the pain associated with his infarction. 9/98 medslides.com
Case Study 1 Physical Exam: Afebrile No pericardial friction rub ECG: mild PR depression in lead 2 no significant change in the evolution pattern of his Q-wave anteroseptal myocardial infarction 9/98 medslides.com
Case Study 1 The most appropriate therapy for this patient is: Salicylates Indomethacin Corticosteroids Colchicine 9/98 medslides.com
Case Study 2 A 36-year old woman presents to the ER for the second time in a week with pleuritic chest and left shoulder discomfort and a low-grade fever. She had been in an argument with her boy friend 6 days earlier during which he grabbed her by both shoulders and shook her violently. 9/98 medslides.com
Case Study 2 HR 82, BP 94/70. Left iris is green, right is blue She is slender, has a straight back, long fingers, high-arched palate, and slight pectus excavatum. A pericardial friction rub is present. 9/98 medslides.com
Case Study 2 A chest radiograph shows an increased cardiac silhouette and a small left pleural effusion. ECG shows NSR with diffuse J-point elevation and PR-segment depression in lead 2. 9/98 medslides.com
Case Study 2 Which one of the following tests should you order? An erythrocyte sedimentation rate A creatine kinase determination An echocardiogram An antinuclear antibody A D-dimer 9/98 medslides.com
Constrictive Pericarditis rarely develop after an episode of acute idiopathic pericarditis more likely to develop after subacute pericarditis with effusion that evolve over several weeks more frequent after purulent bacterial or tuberculous pericarditis 9/98 medslides.com
Constrictive Pericarditis in the United States Idiopathic radiotherapy cardiac surgery connective tissue disorders dialysis bacterial infection 9/98 medslides.com
CONSTRICTIVE PERICARDITIS 9/98 medslides.com
Tuberculous Pericarditis Incidence of pericarditis in patients with pulmonary TB ranged from 1-8% Physical findings: fever, pericardial friction rub, hepatomegaly TB skin test usually positive Fluid smear for TB often negative Pericardial biopsy more definitive 9/98 medslides.com
Constrictive Pericarditis Physical Findings Jugular veins prominent X and Y descent with inspiration (Kussmaul’s sign) Lungs - possible pleural effusion Heart - diastolic pericardial knock Abdomen: ascites, pulsatile liver Extremities: peripheral edema 9/98 medslides.com
Constrictive Pericarditis Diagnosis often not recognized in its early phases by exam, x-ray, ECG, echo tendency to overlook elevated JVP subacute chronic diastolic knock + ++ Kussmaul’s + ++ paradoxical pulse ++ ++ 9/98 medslides.com
Constrictive Pericarditis catheterization findings Right and left heart pressure are measured simultaneously right and left ventricular diastolic pressure are elevated and nearly equal; may show classic “square root sign” RA pressure has steep X and Y descents and may rise during inspiration (Kussmaul’s sign) 9/98 medslides.com
Case Study 3 A 42-year old man presented because of increasing abdominal girth and lower extremity edema. A decade ago he underwent treatment for Hodgkin’s disease that included mantle field radiation therapy and MOPP chemotherapy. 9/98 medslides.com
Case Study 3 HR 84, BP 100/70 JVD not observed at 45 degrees Absent vocal fremitus at right base Heart sound is distant An early-mid diastolic sound 3+ pitting edema bilaterally 9/98 medslides.com
Case Study 3 What is the most likely diagnosis? Effusive pericarditis Occult constrictive pericarditis Constrictive pericarditis Idiopathic dilated cardiomyopathy Restrictive cardiomyopathy 9/98 medslides.com
Types of Effusive Fluid serous transudative - heart failure suppurative pyogenic infection with cellular debris and large number of leukocytes hemorrhagic occurs with any type of pericarditis especially with infections and malignancies serosanguinous 9/98 medslides.com
Dignostic Evaluation Chest x-ray Echocardiography usually requires > 200 ml of fluid cannot distinguish between pericardial effusion and cardiomegly Echocardiography standard for diagnosing pericardial effusion convenient, highly reliable, cost effective false positives (M-mode)- left pleural effusion, epicardial fat, tumor tissue, pericardial cysts 9/98 medslides.com
Noncompressing Effusion asymptomatic unless they are large enough to compress adjacent organs dysphagia cough dyspnea hoarseness hiccups abdminal fullness nausea 9/98 medslides.com
ECG in Pericardial Effusion Diffuse low voltage amount of fluid electrical conductivity of the fluid Electrical alternans alternating amplitude of the QRS produced by heart swinging motion also seen in PSVT, HTN, ischemia 9/98 medslides.com
Cardiac Tamponade Decompensated cardiac compression from increased intracardaic press 9/98 medslides.com
Cardiac Tamponade Early stage Advanced stage mild to moderate elevation of central venous pressure Advanced stage intrapericardial pressure ventricular filling, stroke volume hypotension impaired organ perfusion 9/98 medslides.com
Beck’s Triad Described in 1935 by thoracic surgeon Claude S. Beck 3 features of acute tamponade Decline in systemic arterial pressure Elevation in systemic venous pressure (e.g. distended neck vein) A small, quiet heart 9/98 medslides.com
Cardiac Tamponade Bedside Diagnosis Elevated jugular venous pressure Paradoxical pulse 9/98 medslides.com
Pulsus Paradoxus an exaggerated drop in blood pressure with inspiration (>10mmHg) tamponade without pulsus atrial septal defect aortic insufficiency LVH with LVEDP pulsus without tamponade COPD, RV infarct, pulmonary embolism 9/98 medslides.com
Echocardiography Pericardial effusion Cardiac tamponade highly reliable Cardiac tamponade RA and RV diastolic collapse reduced chamber size distension of the inferior vena cava exaggerated respiratory variation of the mitral and tricuspid valve flow velocities 9/98 medslides.com
Pericardiocentesis Diagnostic tap Therapeutic drainage usually not indicated rarely have positive cytology or infection that can be diagnosed Therapeutic drainage indicated for significant elevation of the central venous pressure 9/98 medslides.com
Pericardial Window Balloon dilatation of a needle pericardiostomy subxyphoid surgical pericardiostomy video-assisted thoracoscopy with localized pericardial resection anterolateral thoracotomy with parietal pericardial resection 9/98 medslides.com
Localized and Low Pressure Cardiac Tamponade Localized tamponade due to loculated pericardial effusion Low pressure tamponade due to relative intravascular volume depletion 9/98 medslides.com
Restrictive Cardiomyopathy Differentiation from constrictive pericarditis may be difficult from intracardiac pressure tracings clues from history, physical exam, ECG, echo, CT and MR scan amyloidosis is most likely to simulate constrictive pericarditis 9/98 medslides.com