Download constrictive pericarditis

Pericardial Disease
The normal pericardium is a doublelayered sac
1. Visceral pericardium is a serous
membrane that is separated by a small
quantity (15–50 mL) of fluid
2. Fibrous parietal pericardium

The normal pericardium, by exerting a
restraining force, prevents sudden dilation of
the cardiac chambers, especially the right
atrium and ventricle, during exercise and
with hypervolemia.
2. Restricts the anatomic position of the heart,
minimizes friction between the heart and
surrounding structures,prevents
displacement of the heart and kinking of
the great vessels,
3. Retards the spread of infections from the
lungs and pleural cavities to the heart.
1.

Total absence of the pericardium, either
congenital or after surgery, does not
produce obvious clinical disease.
Acute Pericarditis
Chest pain
1. Severe, retrosternal and left precordial,
and referred to the neck, arms, or left
shoulder
2. Pleuritic
3. Pericardial pain may be relieved by
sitting up and leaning forward and is
intensified by lying supine

Pericardial friction rub
1. Audible in about 85% of these patients
2. Heard most frequently at end expiration
with the patient upright and leaning
forward
3. Inconstant

ECG
1. Widespread elevation of the ST
segments, often with upward concavity
2. Reciprocal depressions only in aVR and
sometimes V1
3. Depression of the PR segment below
the TP segment
 Cardiac enzymes

I. Infectious pericarditis
A.Viral (coxsackievirus A and B, echovirus,
mumps, adenovirus, hepatitis, HIV)
B. Pyogenic (pneumococcus, streptococcus,
staphylococcus, Neisseria, Legionella)
C. Tuberculous
D. Fungal (histoplasmosis,
coccidioidomycosis, Candida,
blastomycosis) E. Other infections
(syphilitic, protozoal, parasitic)
II. Noninfectious pericarditis
A.Acute myocardial infarction
B. Uremia
C. Neoplasia
D. Myxedema
E. Cholesterol
F. Chylopericardium
G. Trauma (1. Penetrating chest wall 2.
Nonpenetrating (
H. Aortic dissection (with leakage into
pericardial sac)
I. Post irradiation
III. Hypersensitivity or autoimmunity
A. Rheumatic fever
B. Collagen vascular disease (systemic lupus
erythematosus, rheumatoid arthritis, ankylosing
spondylitis, scleroderma, acute rheumatic fever,
C. Drug-induced (e.g., procainamide,
hydralazine, phenytoin, isoniazide,
minoxidil, anticoagulants)
D. Post-cardiac injury
1. Postmyocardial infarction (Dressler's syndrome)
2. Postpericardiotomy 3. Posttraumatic
Classification of Pericarditis
I. Acute pericarditis (<6 weeks)
II. Subacute pericarditis (6 weeks to 6
months)
III. Chronic pericarditis (>6 months)
Rx
Patients with acute pericarditis should
be observed frequently for the
development of an effusion; if a large
effusion is present, the patient should be
hospitalized
 Nonsteroidal anti-inflammatory drugs
such as ibuprofen (400–600 mg tid),
indomethacin (25–50 mg tid), or
colchicine (0.6 mg bid), Glucocorticoids
(e.g., prednisone, 40–80 mg daily)

Postcardiac Injury Syndrome
Previous injury to the myocardium with
blood in the pericardial cavity.
 After a cardiac operation (post
pericardiotomy syndrome), after blunt or
penetrating cardiac trauma or after
perforation of the heart with a catheter.
 After AMI

The principal symptom is the pain of
acute pericarditis, which usually develops
1 to 4 weeks after the cardiac injury (1 to
3 days after AMI) but sometimes appears
only after an interval of months
 Pericarditis, fever with temperature up to
39°C (102.2°F), pleuritis, and pneumonitis

Cardiac Tamponade
Cardiac Tamponade
The accumulation of fluid in the
pericardial space in a quantity sufficient to
cause serious obstruction to the inflow of
blood to the ventricles results in cardiac
tamponade.
 This complication may be fatal if it is not
recognized and treated promptly.

The three most common causes of
tamponade are neoplastic disease,
idiopathic pericarditis, and renal failure
 Bleeding into the pericardial space after
cardiac operations, trauma, and treatment
of patients with acute pericarditis with
anticoagulants

Beck's triad: hypotension, soft or absent
heart sounds, and jugular venous
distention
 Electrical alternans of the P, QRS, or T
waves should raise the suspicion of
cardiac tamponade

Paradoxical Pulse

Greater than normal (10 mmHg)
inspiratory decline in systolic arterial
pressure
Rx
Pericardiocentesis
 Pericardial window

Constrictive
Pericarditis
acute or relapsing viral or idiopathic
pericarditis,
2. trauma with organized blood clot,
3. cardiac surgery of any type,
4. mediastinal irradiation,
5. purulent infection,
6. neoplastic disease (especially breast
cancer, lung cancer, and lymphoma),
7. rheumatoid arthritis, SLE,
8. chronic renal failure with uremia treated
by chronic dialysis
1.

In constrictive pericarditis, ventricular
filling is unimpeded during early diastole
but is reduced abruptly when the elastic
limit of the pericardium is reached,
whereas in cardiac tamponade, ventricular
filling is impeded throughout diastole
RESPIRATORAY
VARIATION
Weakness, fatigue, weight gain, increased
abdominal girth, abdominal discomfort,
and edema are common.
 The patient often appears chronically ill,
and in advanced cases there are anasarca,
skeletal muscle wasting, and cachexia.
Exertional dyspnea is common

The cervical veins are distended and
venous pressure may fail to decline during
inspiration (Kussmaul's sign).
 Congestive hepatomegaly is pronounced
and may impair hepatic function and cause
jaundice;
 Ascites is common and is usually
more prominent than dependent
edema

Characteristic
Tamponade
Constrictive
Pericarditis
Pulsus paradoxus
Common
Usually absent
Kussmaul's sign
Absent
Present
Pericardial knock
Absent
Often present
Electrical alternans
May be present
Absent
Pericardial effusion
Present
Absent
Thickened pericardium
Absent
Present
Pericardial calcification
Absent
Often present