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Pericardial Disease By Dr. Muhammad Aftab Shah Senior Registrar Cardiology KEMU/Mayo Hospital, Lahore. 1 Pericardial Disease • • • • • Acute Pericarditis Chronic Relapsing Pericarditis Constrictive Pericarditis Cardiac Tamponade Localized and Low Pressure Tamponade • Restrictive Cardiomyopathy 2 Pericardial Anatomy • Two major components – serosa (viceral pericardium) mesothelial monolayer facilitate 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 3 9/98 medslides.com 4 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 5 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 6 9/98 medslides.com 7 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 8 PERICARDITIS 9 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, varicellazoster, influenza, Epstein-Barr, HIV 10 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 11 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 12 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 13 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) 14 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 15 16 17 18 Acute Pericarditis Management • 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 19 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 20 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 21 Noncompressing Effusion • asymptomatic unless they are large enough to compress adjacent organs – – – – – – – dysphagia cough dyspnea hoarseness hiccups abdminal fullness nausea 22 Cardiac Tamponade • Decompensated cardiac compression from increased intracardaic press 23 Cardiac Tamponade • Early stage – mild to moderate elevation of central venous pressure • Advanced stage – intrapericardial pressure ventricular filling, stroke volume – hypotension – impaired organ perfusion 24 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 25 Cardiac Tamponade Bedside Diagnosis • Elevated jugular venous pressure • Paradoxical pulse 26 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 27 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 28 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 29