Pericardial Diseases

 

• Acute pericarditis

  Pathophysiology

  Inflammation of the pericardium. Causes:

  • Usually idiopathic or viral: Coxsackie, Herpesviridae (CMV, EBV, HSV), flu, mumps, HIV.
  • Bacteria: staph, strep, haemophilus, TB.
  • Fungi
  • Acute MI and post-MI Dressler's syndrome.
  • Drugs: procainamide, hydralazine.
  • Autoimmune: SLE, RA, sarcoidosis.
  • Other: uraemia, chest trauma, hypothyroidism, cancer.

  Signs and symptoms

  • Chest pain which is worse on lying down and inspiration (pleuritic), and relieved by sitting forward.
  • Pericardial friction rub (scratchy noise).
  • Fever

  Investigations

  • ECG: ST elevation. Can be distinguished from STEMI as it is saddle shaped, diffuse (i.e. in >1 coronary artery territory), and lacks reciprocal ST depression.
  • Bloods: FBC, CRP/ESR, U+E, troponin (raised in ⅓ of patients).
  • Investigations of cause: viral serology, blood culture, TFT.
  • CXR and echo: may show effusion.

  Management

  • NSAIDs
  • Add colchicine if viral or idiopathic.
  • Treat cause.

  Complications

  • Pericardial effusion, which may in turn lead to tamponade.
  • Recurrence in 25%.
  • Constrictive pericarditis.

• Constrictive pericarditis

  Pathophysiology

  Rigid, fibrotic pericardium. Causes:

  • Iatrogenic: interventional treatment or open cardiac surgery.
  • Idiopathic
  • Acute pericarditis.
  • Consider TB if from endemic area.

  Signs and symptoms

  Similar to restrictive cardiomyopathy, namely:

  • Heart failure symptoms, primarily RVF. Includes SOB and cough (due to pleural effusion and ascites); hepatomegaly and abdo pain; and peripheral oedema.
  • ↑JVP with rapid x + y descents.
  • Kussmaul's sign: ↑JVP on inspiration.
  • Muffled heart sounds.
  • Pericardial knock: early, high-pitched S3.

  Investigations

  • ECG: reduced voltage, P mitrale, AF, T inversion.
  • CXR: pleural effusion (40%), pericardial calcification (30%).
  • Echo is the diagnostic tool of choice. CT, MRI, or cardiac catheterization if further information/clarification needed.

  Management

  Pericardiectomy is usually required, though TB pericarditis often responds to medical therapy.

• Pericardial effusion

  Pathophysiology

  • Fluid in pericardial sac.
  • Usually due to acute pericarditis, especially idiopathic/viral (40%) and cancer (30%).

  Signs and symptoms

  • May be asymptomatic or just the symptoms of the underlying cause (e.g. fever).
  • When severe and progressing to tamponade, may develop SOB and ↑JVP with prominent x descent.

  Investigations

  • CXR: large cardiac silhouette.
  • ECG: ↑HR, low voltage QRS complexes.
  • Echo: echolucent area around the heart.

  Management

  • Treat underlying cause e.g. NSAIDs and colchicine for acute pericarditis, chemotherapy for cancer.
  • Pericardiocentesis can be therapeutic – for impending tamponade – and/or diagnostic – for purulent effusions or suspected malignancy. Investigations include culture, stain, and cytology.

  Complications

  Tamponade.

• Cardiac tamponade

  Pathophysiology

  Fluid in pericardial sac accumulates until ↑pressure causes ↓ventricular filling and ↓cardiac output.

  Causes, TAMP:

  • Trauma
  • Aortic dissection.
  • Medical (iatrogenic): cardiac catheterization causing septal puncture, cardiac biopsy.
  • Pericardial effusion and its causes e.g. infection, cancer.

  Signs and symptoms

  • Beck's triad: ↓BP, ↓heart sounds, ↑JVP.
  • ↑HR
  • Pulsus paradoxus: ↓BP with inspiration.

  Investigations

  • ECG: ↑HR, low voltage, electrical alternans.
  • CXR: large cardiac silhouette.
  • Echo

  Management

  Urgent pericardiocentesis.