Pericardial Diseases
• Visceral – single layer mesothelial cells
• Parietal- fibrous < 2 mm thick
• Functions
– Limits motion
– Prevents dilatation during volume increase
– Barrier to infection
• 15-50 ml serous fluid
• Well innervated
1
Acute Pericarditis Etiology
• Infectious
– Viral
– Bacterial
– TB
• Noninfeccious
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Post MI (acute and Dresslers)
Uremia
Neoplastic disease
Post radiation
Drug-induced
Connective tissue diseases/autoimmune
traumatic
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Infectious
• Viral (idiopathic)
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Echovirus, coxsackie B
Hepatitis B, influenza, IM, Caricella, mumps
HIV, TB
Bacterial (purulent)
• Pneuococcus, staphlococci
• fulminant
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Pericarditis post- MI
• Early <5% patients
• Dressler’s 2 weeks – months
– Autoimmune
• Post-pericardiotomy
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Neoplastic
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Breast
Lung
Lymphoma
Primary pericardail tumors rare
Hemmorrhagic and large
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• Radiation
– Dose > 4000rads
– Local inflammation
• Autoimmune
– SLE
– RA
– PSS (40% may develop)
• Drugs-lupus like
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Hydralazine
Procaimamide
Phenytoin
Methyldopa
Isoniazid
• Drugs- not lupus
– Minoxidil
– Anthracycline antineoplastic agents
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Pathogenesis and Pathology
• Inflammatory
– Vasodilation
– Increased vascular permeability
– Leukocyte exudation
• Pathology
– Serous-little cells
– Serofibrinous – rough appearance / scarring
• common
– Purulent – intense inflammation
– Hemmorrhagic – TB or malignancy
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Clinical
• Chest pain
– Radiate to back
– Sharp and pleuritic
– Positional – worse lying back
• Fever
• Dyspnea due to pleuritic pain
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Chest pain in Pericarditis
• เจ็บบริเวณหลังต่ อกระดูก sternum
• เจ็บมากเวลาหายใจ และเวลานอนหงาย
• เจ็บน้ อยลงเวลาลุกนั่ง และ โน้ มตัวไปด้ านหน้ า
Exam
• Friction rub
– Diaphragm leaning forward
– 1, 2 or 3 components
• Ventricular contraction, relaxaltion, atrial
contraction
– intermittent
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Diagnostic
• Clinical history
• ECG
– Abn in 90%
– Diffuse ST elevation
– PR depression
• Echocardiography
– Effusion
• PPD
• Autoimmune antibodies
• Evaluate for malignancy
11
(Circulation. 2006;113:1622-1632.)
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EKG in Pericarditis
(Circulation. 2006;113:1622-1632.)
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Treatment
• ASA or NSAIDs
– Avoid NSAID in MI
• Colchicine
• Steroids - avoid
– May increase reoccurance
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TB – Rx TB
Purulent – drainage of fluid + antibiotics
Neoplastic- drainage
Uremic - dialysis
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Pericardial Effusion
• From any acute pericarditis
• Hypothyriodism- increased capillary
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permeability
CHF- increased hydrostatic pressure
Cirrhosis- decreased plasma oncotic
pressure
Chylous effusion- lymphatic obstruction
Aortic Dissection
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Effusion Pathophysiology
• Pericardium is stiff- PV curve not flat
• Above critical volume – rapid increase in
pressure
• Factors that determine compression
– Volume
– Rate of accumulation
– Pericardial compliance
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Clinical
• Asymptomatic
• Symptoms
– CP, dyspnea, dysphagia, hoarseness, hiccups
• Tamponade
• Exam
– Muffled heart sounds
– Absence of rub
– Ewarts sign-dullness L lung at scapula
• atelectasis
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Diagnostic studies
• CXR - > 250 ml fluid globular
cardiomegaly
• ECG low voltage and electrical alternans
• Echocardiogram most helpful
– Identify hemodynamic compromise
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ECG low voltage and electrical alternans
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Treatment
• If known cause- treat that
• If unknown- may need pericardiocentesis or
pericardial window
• Cardiac tamponade is emergencypericardiocentesis drainage or window
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Tamponade
• Any cause of effusion may lead to
• Diastolic pressures elevate and = pericardial
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pressure
Impaired LV/RV filling
Increased systemic venous pressure
Decreased stroke volume and C.O.
Shock
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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
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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
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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.
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Tamponade- external compression blunts filling
throughout cardiac cycle
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Lancet 2004; 363: 717–27
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Pericardial Fluid
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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
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Constrictive Pericarditis
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Most common etiology is idiopathic (viral)
Any cause of pericarditis
Post cardiac surgery
Pathology
– Organization of fluid, scarring, fusion of
pericardial layers, calcification
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Constrictive Pericarditis
• Impaired diastolic
filling of the chambers
• Elevated systemic
venous pressures
• Reduced cardiac
output
• Dip and plateau curve
on catheterization
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Constrictive Pericarditis
Clinical
• Symptoms
– Fatigue, hypotension, tachycardia
– JVD, hepatomegaly and ascites, edema
• Can confuse with cirrhosis- look for JVD
• Exam
– Pericardial knock after S2- sudden cessation of
ventricular diastolic filling
• Kussmaul’s sign- JVD with inspiration
• No pulsus paradoxus
• Difficult to separate from restrictive
cardiomyopathy- may need myocardial biopsy
34
Am Heart J 1999;138:219-32
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Normal pericardium < 2 mm
36
(Circulation. 2006;113:1622-1632