CARDIO A – Feb 2014

Pericardial  Disease  
Normal Functions of the Pericardium Table 222-1 Classification of Pericarditis
Clinical Classification
• Prevents sudden dilatation of the cardiac chambers
I. Acute Pericarditis (<6 weeks)
during exercise and with hypervolemia a. Fibrinous
• Pericardial sac facilitates atrial filling during b. Effusive (serous or sanguinous)
ventricular systole II. Subacute pericarditis (6 weeks-6months)
• Restricts the anatomic position of the heart, a. Effusive-constrictive
minimizes friction between the heart and b. Constrictive
surrounding structures prevents displacement of the III. Chronic pericarditis (>6 months)
a. Constrictive
heart and kinking of the great vessels
b. Effusive
• Retards the spread of infections from the lungs and c. Adhesive (nonconstrictive)
pleural cavities to the heart Etiologic Classification
I. Infectious Pericarditis
a. Viral (Coxsackievirus A and B, Echovirus, mumps,
Acute Pericarditis adenovirus, hepatitis, HIV)
The most common pathologic process involving the b. Pyogenic (pneumococcus, streptococcus,
staphylococcus, Neisseria, Legionella)
pericardium c. Tuberculosis
d. Fungal (histoplasmosis, coccidioidomycosis, Candida,
Cardinal Manifestations blastomycosis)
Chest pain e. Other infections (syphilitic, protozoal, parasitic)
• Often severe II. Noninfectious pericarditis
• Retrosternal and left precordial a. Acute myocardial infarction
b. Uremia
• Referred to the back and left trapezius ridge c. Neoplasia
• Relieved by sitting up and leaning forward i. Primary tumors (benign or malignant,
• Intensified by lying supine mesothelioma)
ii. Tumors metastatic to pericardium (lung
Pericardial friction rub and breast cancer, lymphoma, leukemia)
d. Myxedema
• The most important physical sign of acute e. Cholesterol
pericarditis f. Chylopericardium
g. Trauma
i. Penetrating chest wall
ii. Nonpenetrating
h. Aortic dissection (with leakage into pericardial sac)
i. Postirradiation
j. Familial Mediterranean fever
k. Familial pericarditis
i. Mulibrey nanism*
l. Acute idiopathic
m. Whipple’s disease
n. Sarcoidosis
III. Pericarditis presumably related to hypersensitivity or
autoimmunity
a. Rheumatic fever
b. Collagen vascular disease (SLE, rheumatoid arthritis,
ankylosing spondylitis, scleroderma, acute rheumatic
fever, Wegener’s granulomatosis)
c. Drug-induced (procainamide, hydralazine, phenytoin,
isoniazide, minoxidil, anticoagulants, methysergide)
d. Postcardiac injury
i. Postmyocardial infarction (Dressler’s
syndrome)
ii. Postpericardiotomy
iii. Posttraumatic
*An AR syndrome characterized by growth failure, muscle hypotonia,
hepatomegaly, ocular changes, enlarged cerebral ventricles, MR, chronic
constrictive pericarditis

eusebio 1
CARDIO A – Feb 2014
Electrocardiogram (ECG)
• 2º to acute subepicardial inflammation
• Widespread elevation of the ST segments, with reciprocal depressions only in aVR and sometimes V1
• After several days, the ST segments return to normal and only then do the T waves become inverted
• Sequential ECGs are useful in distinguishing acute pericarditis from acute myocardial infarction
• With large pericardial effusions, the QRS voltage is reduced

Figure 239-1 Acute pericarditis often produces diffuse ST-segment elevations (in this case in leads I, II, aVF, and V 2 to V 6 ) due to a ventricular
current of injury. Note also the characteristic PR-segment deviation (opposite in polarity to the ST segment) d/t a concomitant atrial injury current.

Pericardial Effusion
May lead to cardiac tamponade
Heart sounds tend to become faint
Ewart’s sign – a patch of dullness beneath the angle of the left scapula base of the left lung may be compressed by pericardial fluid,
producing
Chest roengenogram - “water bottle”configuration of the cardiac silhouette but may also be normal
Pericardial fat lines may be seen deep within the cardiopericardial silhouette
Fluoroscopic examination – diminished ventricular pulsations

Diagnosis
Echocardiography
• The most effective diagnostic lab technique available
Computed tomography (CT) Scan or Magnetic resonance imaging (MRI)
• May be superior to echocardiography in detecting loculated pericardial effusions and pericardial thickening
Pericardiocentesis
• For diagnostic and/or therapeutic purposes

Cardiac Tamponade
Accumulation of fluid in pericardium in amount sufficient to more than 2000 mL in slowly developing effusions when the
cause serious obstruction to the inflow of blood to the pericardium has had the opportunity to stretch and adapt to
ventricles may be fatal if it is not recognized and treated an increasing volume (rate of accumulation)
promptly
The volume of fluid required to produce tamponade also
Three most common causes of tamponade varies directly with the thickness of the ventricular
• Neoplastic disease myocardiumand inversely with the thickness of the parietal
• Idiopathic pericarditis pericardium
• Uremia
Classic findings of falling arterial pressure, rising venous pressure,
and faint heart sounds usually occur only with severe,
Three principal features of tamponade
acute tamponade, as occurs with cardiac trauma or rupture
• Elevation of intracardiac pressures
• Limitation of ventricular filling Tamponade may also develop more slowly, and under these
• Reduction of cardiac output circumstances the clinical manifestations may resemble those
of heart failure, including dyspnea, orthopnea, hepatic
Quantity of fluid necessary to produce this critical state may engorgement, and jugular venous hypertension.
be as small as 200 mL when the fluid develops rapidly or
eusebio 2
CARDIO A – Feb 2014
Paradoxical Pulse – consist of a greater than normal 10
mmHg inspiratory decline in systolic arterial pressure
Right Ventricular Infarction
May resemble cardiac tamponade with hypotension, elevated
jugular venous pressure, an absent y descent in the jugular
venous pulase, and occasionally pulsus paradoxus
Paradoxical pulse occurs not only in cardiac tamponade
• Constrictive pericarditis – approximately 1/3 of
patients
• Hypovolemic shock
• Acute and chronic obstructive airways disease
• Pulmonary embolus
Viral or Idiopathic form of Acute Pericarditis
• An antecedent infection of the respiratory tract, but
in many patients such an association is not evident
and viral isolation and serologic studies are negative.
• Acute idiopathic pericarditis - a viral causation cannot
be established
• Occurs at all ages; but more frequent in young
adults
• Often associated with pleural effusions and
pneumonitis.
• Course of disease: few days to 4 weeks
• One or more recurrences occur in about one-fourth
of patients
• Tamponade is unusual, and constrictive pericarditis
is a possible complication
Low-pressure tamponade
• Mild tamponade
• Intrapericardial pressure is increased from its
slightly subatmospheric levels to +5 to +10 mmHg
• In some instances, hypovolemia coexists
Diagnosis
Echocardiography
• During inspiration right ventricular diameter
increases while left ventricular diameter and mitral
valve opening decrease
• Late diastolic inward motion (collapse) of the right
ventricular free wall and of the right atrium
Doppler Ultrasound
• Exaggerated pulmonic (and tricuspid) flow during
inspiration, with reciprocal changes in aortic (and
mitral) flow
Cardiac catheterization
• Equalization" of pressures, i.e., the pulmonary artery
wedge is equal, or close, to right atrial, right
ventricular, and pulmonary artery diastolic
pressures
• Amputation of Y descent
Treatment
For large effusion
• Hospitalized and watched closely for signs of
tamponade
Presence of effusion
• Monitor arterial &venous pressures and heart rate
• Obtain serial echocardiograms.
Manifestations of tamponade
• Pericardiocentesis AT ONCE; relief of
intrapericardial pressure may be lifesaving.
Surgical drainage through a limited thoracotomy
• In recurrent tamponade and/or when it is necessary
to obtain tissue for diagnosis
Treatment
• No specific therapy
• Bed rest
• Anti-inflammatory treatment
o Aspirin - if necessary up to 900 mg qid
o Indomethacin - 25 to 75 mg qid
o Glucocorticoid - prednisone, 40 to 80 mg
daily
• Anticoagulants should be avoided
• Recurrences are multiple, frequent, disabling, and
continue beyond 2 years
• Pericardiectomy may be effective in terminating the
illness
eusebio 3
CARDIO A – Feb 2014
Post-Cardiac Injury Syndrome
After:
• Cardiac operation (postpericardiotomy syndrome)
• Cardiac trauma or after perforation of the heart with
a catheter
• Rarely follows MI (Dressler’s syndrome)
Clinical picture
• Mimics acute viral or acute idiopathic pericarditis
• Us develops 1-4 weeks following cardiac injury
• Sometimes appears only after an interval of months
• Recurrences of pericarditis are common and may
occur up to 2 years or more after the injury
• Probably the result of a hypersensitivity reaction
• Therapy with a nonsteroidal anti-inflammatory
agent or a glucocorticoid is usually effective
Differential Diagnosis
Acute idiopathic pericarditis
• Diagnosis is one of exclusion
• Dressler's syndrome
o Aform post-cardiac injury pericarditis
o Occurs a week or two following MI
Pericarditis secondary to post-cardiac injury is differentiated
from acute idiopathic pericarditis chiefly by timing
Pericarditis due to collagen vascular disease
Systemic lupus erythematosus or drug-induced (procainamide
or hydralazine) lupus
Acute pericarditis may complicate the viral, pyogenic,
mycobacterial, and fungal infections that occur in AIDS
Acute pericarditis is an occasional complication of rheumatoid
arthritis, scleroderma, and polyarteritis nodosa
Ingestion of procainamide, hydralazine, isoniazid, cromolyn,
and minoxidil
Chronic Pericardial Effusions
Tuberculosis
• (+) Caseation necrosis - antituberculous chemotherapy is indicated
• Thickened pericardium - pericardiectomy should be carried out
Other Causes of Chronic Pericardial Effusion
• Myxedema
• Neoplasms
• Systemic lupus erythematosus
• Rheumatoid arthritis
• Mycotic infections
• Radiation therapy
• Pyogenic infections
• Severe chronic anemia
• Chylopericardium
Acute rheumatic fever
• Generallyassocw evidence of severe pancarditis and
with cardiac murmurs
Pyogenic (purulent) pericarditis
Usually 2º to:
• Cardiothoracic operations
• Immunosuppressive therapy
• Rupture of esophagus into the pericardial sac
• Rupture of ring abscess frominfective endocarditis
• Septicemia complicating aseptic pericarditis
• Accompanied by fever, chills, septicemia, & evidence
of infection elsewhere
Tuberculous pericarditis - evidence of pulmonary or
mediastinal tuberculosis
• May present as a chronic asymptomatic effusion, as
subacute effusive-constrictive pericarditis, or as
frank chronic constrictive pericarditis
Uremic pericarditis
• Occurs in up to 1/3 of patients with chronic uremia
• Seen most frequently in patients undergoing chronic
hemodialysis
• Treatment with an anti-inflammatory agent and
intensification of hemodialysis is usually adequate
Neoplastic diseases
• Results from extension or invasion of metastatic
tumors (most commonly carcinoma of the lung and
breast, malignant melanoma, lymphoma, and
leukemia)
Mediastinal irradiation
• May cause acute pericarditis and/or chronic
constrictive pericarditis after eradication of the
tumor
eusebio 4
CARDIO A – Feb 2014
Chronic Constrictive Pericarditis
Healing of an acute fibrinous or serofibrinous pericarditis or a chronic pericardial effusion
• Obliteration of thepericardial cavity w formation of granulation tissue and forms
a firm scar, encasing the heart and interfering with filling of the ventricles
• Ventricular filling is unimpeded in early diastole but is reducedabruptly when
elastic limit of the pericardium is reached
o In cardiac tamponade, ventricular filling is impeded throughout diastole
• REDUCED – Ventricular end-diastolic and stroke volumes
• ELEVATED
o End-diastolic pressures in both ventricles and the mean pressures in the
atria, pulmonic veins, and systemic veins are all elevated to similar
levels, i.e., within 5 mmHg
• CVP, RAP, AND LAPpulses display an M-shaped contour, with prominent x
and y descents
Figure 1 The ventricular pressure pulses in both ventricles exhibit
characteristic "square root" signs during diastole
Table 239-2. Features that Distinguish Cardiac Tamponade from Constrictive Pericarditis and Similar Clinical Disorders
Characteristic Tamponade Constrictive Restrictive RVMI
Pericarditis Cardiomyopathy
CLINICAL
Pulsus paradoxus Common Usually absent Rare Rare
JUGULAR VEINS
Prominent y descent Absent Usually present Rare Rare
Prominent x descent Present Usually present Present Rare
Kussmaul’s sign Absent Present Absent Present
Third heart sound (S3) Absent Absent Rare May be present
Pericardial knock Absent Often present Absent Absent
ELECTROCARDIOGRAM
Low ECG Voltage May be present May be present May be present Absent
Electrical alternans May be present Absent Absent Absent
ECHOCARDIOGRAPHY
Thickened pericardium Absent Present Absent Absent
Pericardial calcification Absent Often Present Absent Absent
Pericardial effusion Present Absent Absent Absent
RV size Usually small Usually normal Usually normal Enlarged
Myocardial thickness Normal Normal Usually increased Normal
Right atrial collapse and Present Absent Absent Absent
RVDC
Increased early filling, Absent Present Present May be present
mitral flow velocity
Exaggerated respiratory Present Present Absent Absent
variation in flow velocity
CT/MRI
Thickened/calcific Absent Present Absent Absent
pericardium
CARDIAC CATHETERIZATION
Equalization of diastolic Usually present Usually present Usually absent Absent or present
procedures
Cardiac biopsy helpful? No No Sometimes No
a RV, right ventricle; RVMI, right ventricular myocardial infarction; RVDC, right ventricular diastolic collapse; ECG, electrocardiograph
Source: GM Brockington et al, Cardiol Clin 8:645, 1990.

Kussmaul’s Sign • Pulse pressure is normal or reduced

Venous pressure may fail to decline during inspiration • Paradoxical pulse – 1/3 of cases
ü Tricuspid Stenosis • Congestive hepatomegaly and splenomegaly
ü Right ventricular infarction
• Ascites is common and is usually more prominent
ü Restrictive cardiomyopathy
than dependent edema
• Apical pulse is reduced in intensity, retracts in
systole, and moves outward in diastole
eusebio 5
CARDIO A – Feb 2014
Pericardial Knock
Coincides with a sudden deceleration in ventricular filling
absent
Protein-losing gastroenteropathy, due to impaired lymphatic
drainage from the small intestine, and marked proteinuria or
hypoalbuminemia
Diagnostics
Electrocardiography
• Low voltage of the QRS complex
• Diffuse flattening or inversion of the T waves
Chest roentgenogram
• Normal or slightly enlarged heart
• Pericardial calcification
Echocardiogram
• Pericardial thickening
• Atrial enlargement
• Dilatation of the IVC and hepatic veins
• Sharp halt in ventricular filling in early diastole,
with normal ventricular systolic function
• Exaggerated reduction in blood flow velocity in the
pulmonary veins and across the mitral valve during
inspiration with the opposite occurring during
expiration
• Diastolic flow velocity in the vena cavae into the R
atrium and across the tricuspid valve increases in an
exaggerated manner during inspiration and declines
during expiration
• constrictive pericarditis occur
MRI and CT scanning
• More accurate than ECG in establishing or
excluding the presence of a thickened pericardium
Differential Diagnosis
Cor pulmonale
• Advanced parenchymal pulmonary disease is usually
obvious and venous pressure falls during inspiration
o i.e., Kussmaul’s sign is negative
Tricuspid Stenosis
Restrictive Cardiomyopathy
Occult Constrictive Disease
• No manifestations of pericardial disease are present
• Following the rapid intravenous infusion of 1L of
saline solution, diastolic equilibration of intracardiac
atrial and ventricular pressures found in overt
Subacute Effusive-Constrictive Pericarditis
• Combination of a tense effusion in the pericardial
space and constriction of the heart by thickened
pericardium
• Physiologic findings: may change from those of
cardiac tamponade to those of pericardial
constriction following pericardiocentesis
Treatment
Pericardial resection – definitive treatment of
constrictive pericarditis
• Operative mortality - 3-10%
• S/b carried out relatively early in the course
• Patients with the most severe and/or advanced
disease are at highest risk
Other Disorders of the Pericardium
Pericardial Cysts
• Rounded or lobulated deformities of the cardiac
silhouette
• Most commonly at the right cardiophrenic angle
• Clinical significance
o Confusion with tumor, ventricular
aneurysm, or massive cardiomegaly
eusebio 6