Pericardial Diseases
Visceral – single layer mesothelial cellsParietal- fibrous < 2 mm thickFunctionsLimits motionPrevents dilatation during volume increaseBarrier to infection15-50 ml serous fluidWell innervated *Acute Pericarditis Etiology
Infectious Viral Bacterial TB Noninfeccious Post MI (acute and Dresslers) Uremia Neoplastic disease Post radiation Drug-induced Connective tissue diseases/autoimmune traumatic*
Infectious
Viral (idiopathic) Echovirus, coxsackie B Hepatitis B, influenza, IM, Caricella, mumps HIV, TB Bacterial (purulent) Pneuococcus, staphlococci fulminant*
Pericarditis post- MI
Early <5% patientsDressler’s 2 weeks – monthsAutoimmunePost-pericardiotomy *Neoplastic
Breast Lung Lymphoma Primary pericardail tumors rare Hemmorrhagic and large*
Radiation Dose > 4000rads Local inflammation Autoimmune SLE RA PSS (40% may develop) Drugs-lupus like Hydralazine Procaimamide Phenytoin Methyldopa Isoniazid Drugs- not lupus Minoxidil Anthracycline antineoplastic agents
*
Pathogenesis and Pathology
InflammatoryVasodilationIncreased vascular permeabilityLeukocyte exudationPathologySerous-little cellsSerofibrinous – rough appearance / scarringcommonPurulent – intense inflammationHemmorrhagic – TB or malignancy *
Clinical
Chest painRadiate to backSharp and pleuriticPositional – worse lying backFeverDyspnea due to pleuritic pain *Exam
Friction rub Diaphragm leaning forward 1, 2 or 3 components Ventricular contraction, relaxaltion, atrial contraction intermittent*
Diagnostic
Clinical history ECG Abn in 90% Diffuse ST elevation PR depression Echocardiography Effusion PPD Autoimmune antibodies Evaluate for malignancy*
* (Circulation. 2006;113:1622-1632.)
EKG in Pericarditis* (Circulation. 2006;113:1622-1632.)
Treatment
ASA or NSAIDsAvoid NSAID in MIColchicineSteroids - avoidMay increase reoccuranceTB – Rx TB+steroidsPurulent – drainage of fluid + antibioticsNeoplastic- drainageUremic - dialysis *Pericardial Effusion
From any acute pericarditis Hypothyriodism- increased capillary permeability CHF- increased hydrostatic pressure Cirrhosis- decreased plasma oncotic pressure Chylous effusion- lymphatic obstruction*
Effusion Pathophysiology
Pericardium is stiff- PV curve not flatAbove critical volume – rapid increase in pressureFactors that determine compressionVolumeRate of accumulationPericardial compliance *Clinical
Asymptomatic Symptoms CP, dyspnea, dysphagia, hoarseness, hiccups Tamponade Exam Muffled heart sounds Absence of rub*
Diagnostic studies
CXR - > 250 ml fluid globular cardiomegaly ECG low voltage and electrical alternans Echocardiogram most helpful Identify hemodynamic compromise*
ECG low voltage and electrical alternans
*Treatment
If known cause- treat that If unknown- may need pericardiocentesis or pericardial window Cardiac tamponade is emergency- pericardiocentesis drainage or window*
Tamponade
Any cause of effusion may lead to Diastolic pressures elevate and = pericardial pressure Impaired LV/RV filling Increased systemic venous pressure Decreased stroke volume and C.O. Shock*
Tamponade
Have right side failure with edema and fatigue only if occurs slowly Key physical findings: JVD Hypotension Small quiet heart Sinus tachycardia Pulsus paradoxus- decease in BP > 10 during normal inspiration*
Pulsus Paradoxus
Exaggeration of normal Normally septum moves toward LV with inspiration, with decrease in LV filling With compression and fixed volume, there is even greater limitation in LV filling and reduced stroke volume PP also seen in COPD/asthma*
Tamponade
Echocardiography Compression of RV and RA in diastole Can have localized effuison with localized compression of one chamber (RA,LV) Effusion post cardiac surgery Differentiate other causes of low cardiac output Cardiac catheterization- definitive Measure pressures- chamber and pericardial equal, and all elevated.*
* Lancet 2004; 363: 717–27
*
Pericardial Fluid
Stained and cultured Cytologic exam Cell count Protein level pp/sp> 0.5 - exudate LDH level p LDH/ s LDH > 0.6 - exudate Adenosine Deaminase level - sensitive and specific for TB*
Constrictive Pericarditis
Most common etiology is idiopathic (viral) Any cause of pericarditis Post cardiac surgery Pathology Organization of fluid, scarring, fusion of pericardial layers, calcification*
Constrictive Pericarditis
Impaired diastolic filling of the chambers Elevated systemic venous pressures Reduced cardiac output Dip and plateau curve on catheterization*