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

2. 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

3. 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

4. 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

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

6. 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.

7. 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

8. 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)

9. 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

10. 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  

11. 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

12. 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.

13. 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

14. Pericardial effusion
Echocardigram

15. 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

16. 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

17. 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

18. 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

19. THANK
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