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

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

3. Pericardial Anatomy Two major components
serosa (viceral pericardium) mesothelial monolayer facilitate fluid and ion exchange
fibroa (parietal pericardium) fibrocollagenous tissue
Pericardial Fluid
ml of clear plasma ultrafiltrate
Ligamentous attachments
to the sternum, vertebral column, diaphragm

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5. 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

6. 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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8. 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. PERICARDITIS

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

19. Acute Pericarditis Management
Treat underlying cause
Analgesic agents
codeine mg q 4-6 hr
Anti-inflmmatory agents
ASA 648 mg q 3-4 hrs
NSAID (indomethacin mg qid)
Corticosteroids are symptomatically effective , but preferably avoided

20. 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

21. 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

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

23. Cardiac Tamponade
Decompensated cardiac compression from increased intracardaic press

24. 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

25. 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

26. Cardiac Tamponade Bedside Diagnosis
Elevated jugular venous pressure
Paradoxical pulse

27. 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

28. 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

29. 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