Pericardial Disease

1. Pericardial DiseaseBy Dr. Muhammad Aftab ShahSenior Registrar CardiologyKEMU/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 monolayerfacilitate fluid and ion exchange • fibroa (parietal pericardium)fibrocollagenous tissue • Pericardial Fluid • 15 - 50 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 Inflammationpathogenesis • 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 Inflammationpathology • 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 Pericarditiscommon 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 Pericarditiscommon causes • Inpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post) Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder Radiation

12. Acute PericarditisDiagnostic 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 Historypericarditis 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 PericarditisECG 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 PericarditisManagement • Treat underlying cause • Analgesic agents • codeine 15-30 mg q 4-6 hr • Anti-inflmmatory agents • ASA 648 mg q 3-4 hrs • NSAID (indomethacin 25-50 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 • 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 • 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 TamponadeBedside 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 • 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 • usually not indicated • rarely have positive cytology or infection that can be diagnosed • Therapeutic drainage • indicated for significant elevation of the central venous pressure