1. DISEASES OF THE PERICARDIUM
H.A.MWAKYOMA, MD

2. Introduction
The Pericardium is a fibroelastic tissue made up of parietal and visceral layers
These two layers are separated by the pericardial cavity
Pericardial cavity usually contains ml of plasma ultrafiltrate in healthy individuals

3. Diseases of the Pericardium
Pericardial effusion
A. Hemopericardium
B. Cardiac tamponade
2. Pericarditis
A. Serous D. Hemorrhagic
B. Fibrinous E. Constrictive
C. Purulent

4. Pericardial Effusion
Normal: ml of thin serous fluid
Sudden increase: up to 200 ml:
minimal increase in pressure
between 200 and 300 ml:
sharp rise in pressure
Slow increase: up to 2 liters:

5. Pericardial Effusion: Common Causes
Viral myopericarditis
Metastatic malignancy
Autoimmune disease
Drug-induced
Renal failure
Bleeding (Hemopericardium)

6. Pericardial Effusion: Symptoms
Dull constant left chest pain
Dyspnea (shortness of breath)
Less common:
Hiccups (phrenic nerve)
Hoarseness (recurrent laryngeal nerve)
Dysphagia (esophageal compression)

7. Pericardial Effusion: Signs
Muffled soft heart sounds
Dullness to percussion over lower
posterior left lung (Ewart’s sign)
Decrease in pericardial friction rub

8. Pericardial Effusion: Diagnosis
Chest x-ray: if >250 ml: enlarged
globular cardiac silhouette, maybe
ECG: decreased voltage,
(alternating large and small QRS
“electrical alternans” as electrical
axis changes as heart swings to and
fro in a large effusion, cute but rare)

9. Pericardial Effusion: Diagnosis
Echocardiogram: can provide estimate
of size and evidence of tamponade
Pericardiocentesis: low yield,
best reserved for cases with tamponade
when simultaneously diagnostic and
therapeutic

10. Hemopericardium:
Rare, but commonly fatal
Causes:
cardiac rupture after transmural
myocardial infarction (especially day 5),
aortic aneurysm rupture,
chest trauma,
anticoagulation,
leukemia

11. Cardiac Tamponade:
Pericardial effusion or blood
compressing the heart enough to
impair filling and pumping

12. Pericardial Tamponade
Increased Pericardial Pressures leading to compression of all cardiac chambers
Pericardial elasticity maybe limited (Acute vs Chronic)
Cardiac chambers become small and chamber diastolic compliance is reduced
Decreased cardiac filling

13. Cardiac Tamponade: Symptoms: If sudden: confusion,
agitation, dyspnea, collapse, arrest
If slow: fatigue, leg edema, dyspnea

14. Cardiac Tamponade: Signs
Jugular venous distention,
muffled heart sounds and
hypotension (Beck’s triad)
Pulsus paradoxus [misnomer]:
exaggeration of normal decrease in blood pressure with inspiration >10 mm Hg systolic
(not specific, also seen in obstructive
airway disease)

15. Cardiac Tamponade: Diagnosis
Echocardiogram:
diastolic collapse of right atrium and right ventricle
Swan-Ganz right heart catheterization:
increased and equalized right atrial and
left atrial (surrogate: wedge) pressures
Treatment: tap it! (subxiphoid)

16. PERICARDITIS:
Types of Pericarditis
Serous: smooth surface, scant neutrophils,
lymphocytes and macrophages, usually
with effusion of ml of thin fluid
(protein <50% of serum level)
Fibrinous: dry, roughened, shaggy,
“bread and butter” surface, more neutro-
phils, lymphocytes and macrophages,
serofibrinous if with effusion

17. Fibrinous and serofibrinous pericarditis:

18. More Types of Pericarditis
Purulent (synonym: suppurative): red
granular surface coated with pus, lots of
subsurface neutrophils, up to 500 ml
exudate in the pericardium
Hemorrhagic: serous, fibrinous or purulent
plus hemorrhage, +/- effusion or exudate
with blood added
Constrictive: [misnomer] rarely any -itis

19. Purulent (suppurative) pericarditis:

20. Purulent pericarditis is composed of a thin to creamy pus with erythematous, granular serous surfaces

21. Hemorrhagic pericarditis -This is composed of an exudates of blood admixed with fibrinous to suppurative effusion

22. chronic constrictivepericarditis the double layered thin pericardial membranes are turned into a single thick, rigid fibrous capsule, which restricts diastolic filling

23. Acute Pericarditis
The most common disease of the
pericardium
Most common causes
1. Infectious
A. Viral (idiopathic)
B. Pyogenic bacterial
C. Tuberculosis

24. Viral (Idiopathic) Pericarditis
Self-limited, usually over in 1-3 weeks
Most common viruses: Coxsackie
(especially group B) or echovirus
not routinely cultured, so specific
diagnosis requires anti-viral titers,
acute and convalescent 4-6 weeks later
rarely worth doing, so viral pericarditis
= idiopathic (sort of, approximately)

25. Acute Pericarditis: Most common causes
2. Non-Infectious
A. Post myocardial infarction
B. Metastatic malignancy (lung, breast)
C. Autoimmune connective tissue disease
D. Drug-induced (e.g. procainamide)
E. Radiation-induced
F. Renal failure

26. Acute Pericarditis: Symptoms
Pain: substernal, but sharp, pleuritic
(increased with inspiration), positional
(increased with lying down, decreased
with sitting up and leaning forward)
Dyspnea: not exertional
Fever
(Malaise, myalgias, if viral)

27. Acute Pericarditis: Physical & ECG signs
Pericardial friction rub: evanescent,
superficial, scratchy, to and fro,
best heard with stethoscope diaphragm,
with patient leaning forward, exhaling
ECG (abnormal in 90%): ST elevation
diffuse (except aVR, V1) with concavity
upwards, +/-PR depression

28. Acute Pericarditis due to Pyogenic Bacteria
Pathogenesis:
extension of empyema or myocardial abscess
OR seeding of pre-existing effusion
OR hematogenous infection
Evolution: fibrinous adhesions,
organization (fibroblasts), fibrous adhesions,
“constrictive pericarditis”

29. Post Myocardial Infarction Pericarditis:
Two Forms
Extension of visceral pericarditis to
parietal over large transmural infarct,
uncommon, <5% of infarctions
2. Dressler syndrome 2-12 weeks after
infarction, probably autoimmune,
has become rare

30. Autoimmune Pericarditis:
occurs in 30% of patients with lupus
(as part of a polyserositis with
simultaneous pleuritis and peritonitis),
and with rheumatoid arthritis
Drug-induced Pericarditis:
occurs with procainamide
(sometimes as part of a polyserositis),
and with hydralazine

31. Hemorrhagic Pericarditis
Rare, associated with
1. metastatic carcinoma
2. leukemia (thrombocytopenia)
3. tuberculosis
Skin test for tuberculosis (“PPD”)
and chest x-ray: important tests
for unexplained pericarditis

32. Constrictive “Pericarditis”
Encasement of the heart in a dense fibrous
or fibrocalcific scar which prevents
cardiac hypertrophy or dilatation
Rare, commonly due to previous purulent
or tuberculous pericarditis
Pathophysiology similar to tamponade

33. Constrictive Pericarditis
Symptoms: fatigue, leg edema, dyspnea
Signs: jugular venous distention (increased
with inspiration = Kussmaul’s sign),
hepatomegaly, ascites, leg edema

34. Constrictive Pericarditis
ECG: atrial fibrillation (50%),
low voltage
Chest x-ray: calcification (50%)
Cardiac catheterization: dip & plateau
right and left ventricular tracings,
right atrial prominent y descent

35. Cardiac Tamponade
Jugular venous distention, muffled heart
sounds, hypotension, pulsus paradoxus
Echocardiogram: diastolic collapse of
right atrium and right ventricle
Swan-Ganz: equalization of pressures

36. Acute Pericarditis
Most commonly idiopathic (viral),
self-limited to 1-3 weeks with
Sharp substernal pleuritic positional pain
Pericardial friction rub
Diffuse upward concavity ST elevation

37. Examination Question:
1. The pericardial effusion most likely to be
fatal is
A. Hemorrhagic slowly increased to 1500 ml
B. Hemorrhagic suddenly increased to 150 ml
C. Serous slowly increased to 2000 ml
D. Serous suddenly increased to 100 ml
E. Serous suddenly increased to 300 ml

38. Examination Question
2. A red granular pericardial surface is
characteristic of
Constrictive pericarditis
Fibrinous pericarditis
Hemorrhagic pericarditis
Purulent pericarditis
Serous pericarditis

39. Metabolic Disorders Uremia- Severe Hypothyroidism
Most common metabolic cause
6-10 % of ESRD patients not on HD can have Pericarditis
Dialysis related Pericardial Effusions (seen in 13% of patients)
Severe Hypothyroidism
effusion – usually not significant
rarely pericarditis
Ovarian hyperstimulation syndrome
complication of gonadotropin therapy
Due to fluid shifts

40. Malignancy
Responsible for 6% of acute pericardial disease (pericarditis and tamponade)
Accounts for 15-20% of moderate to large pleural effusions
Mets - Lung, Breast, Hodgkin’s metastases
Primary - Mesotheliomas and lipomas

41. Collagen Vascular Disease
SLE- pericardial involvement in up to 50%
Rheumatoid Arthritis
Progressive Systemic Sclerosis
MCTD
Polyarteritis
Giant Cell Arteritis
Inflammatory Bowel Disease

42. Clinical Presentation of Pericarditis
Chest Pain-
sudden onset over anterior chest
sharp and pleuritic
Improves by leaning forward
Radiates commonly to trapezius ridges
Pericardial Friction Rub
ECG – findings depend on stage
2 of 3 needed to make diagnosis +/- effusion.

43. Cardiac Biomarkers Can see elevation in CK, MB, TpnI
22% of patients with Acute Pericarditis in one trial were above TpnI threshold
Transient rise, resolving within the first 7 days
Patients with higher TpnI did not have higher complication rates

44. Physical Exam of Tamponade
Sinus Tachycardia
Elevated JVP
Pulsus Paradoxus
Rub possible
Kussmaul's sign
Less likely w/o constrictive component

45. Pulsus Paradoxus
An exaggerated fall in systemic blood pressure during inspiration
Inspiratory decline in thoracic pressure is transmitted through the pericardium to the right side of the heart
Systemic Venous return increases with inspiration
In tamponade, the rigid pericardium prevents the RV free wall from expanding during diastole causing the pressure transmission to the septal wall and decreased LV filling during inspiration

46. Acute Pericarditis due to Pyogenic Bacteria
Rare, purulent, generally fulminant
High mortality
Most common BACTERIA:
Staphylococcus aureus
Streptococcus pneumoniae