Pericardial Disease By Dr Pericardial Disease By Dr. Muhammad Aftab Shah Senior Registrar Cardiology KEMU/Mayo Hospital, Lahore.

Pericardial Disease Acute Pericarditis Chronic Relapsing Pericarditis Constrictive Pericarditis Cardiac Tamponade Localized and Low Pressure Tamponade Restrictive Cardiomyopathy

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

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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

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

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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

PERICARDITIS

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

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

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

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

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)

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

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

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

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

Noncompressing Effusion asymptomatic unless they are large enough to compress adjacent organs dysphagia cough dyspnea hoarseness hiccups abdminal fullness nausea

Cardiac Tamponade Decompensated cardiac compression from increased intracardaic press

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

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

Cardiac Tamponade Bedside Diagnosis Elevated jugular venous pressure Paradoxical pulse

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

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

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