Far Eastern University NICANOR REYES MEDICAL FOUNDATION

Doctor of Medicine
2019
CARDIOLOGY: PERICARDIAL DISEASES
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

CASE
- A 21-year-old man presents to your emergency department at 2:50 AM
with 8-out-of-10 pleuritic, retrosternal chest pain that radiates to his
back.
- He admits to drinking a few beers the previous night but denies drug
use.
- With the exception of a recent upper respiratory tract infection, he has
been healthy and his past medical history is unremarkable.
- On examination you find him to be a fit-looking young man who is in
obvious discomfort.
- He has an axial temperature of 37.9 and he is diaphoretic, but findings
of his examination are otherwise normal. A 12-lead electrocardiogram
(ECG) reveals 2 mm of ST-segment elevation in multiple leads
- heard most frequently at end expiration with the patient upright and
leaning forward
- high-pitched, and is described as rasping, scratching, or grating
- most frequently at end expiration
- with the patient upright and leaning forward
- The rub is often inconstant, and the loud to-and-fro leathery heard all
thruout respiration
ECG
- Stage 1 – two or three standard limb leads and V2 to V6, with reciprocal
depressions only in aVR and sometimes V1
o ST segment in two or three standard limb leads and V2 to
V6, with reciprocal depressions only in aVR and sometimes
V1
- Stage 2 – ST segments return to normal
- Stage 3 – T waves become inverted
- Stage 4 – ECG returns to normal

PERICARDIAL DISEASES
- Acute Pericarditis
o Cardiac Tamponade
o Viral or Idiopathic Acute Pericarditis
- Chronic Constrictive Pericarditis
PERICARDIUM
- double-layered sac (15-50mL pericardial fluid)
- prevents sudden dilation of the cardiac chambers
- minimizes friction between the heart and surrounding structures
- prevents displacement of the heart and kinking of the great vessels
- retards the spread of infections
- prevents sudden dilation of the cardiac chambers, especially the right
atrium and ventricle, during exercise and with hypervolemia.
- It also 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
- probably retards the spread of infections from the lungs and pleural
cavities to the heart.
PERICARDIAL EFFUSION
- associated with pain and/or the ECG changes, as well as electrical
alternans
- heart sounds may be fainter with pericardial effusion
- chest roentgenogram may show enlargement of the cardiac silhouette,
with a “water bottle” configuration
- heart sounds may be fainter with pericardial effusion
- The base of the left lung may be compressed by pericardial fluid,
producing Ewart’s sign, a patch of dullness and increased fremitus (and
egophony) beneath the angle of the left scapula
- The chest roentgenogram may show a “water bottle” configuration of
the cardiac silhouette but may be normal.

ACUTE PERICARDITIS

ELECTRICAL ALTERNANS
4 PRINCIPAL DIAGNOSTIC FEATURES

CHEST PAIN
- pleuritic, radiates into either arm or both arms
- relieved by sitting up and leaning forward and is intensified by lying
supine
- often severe, retrosternal and left precordial, and referred to the neck,
arms, or left shoulder
- Characteristically, however, pericardial pain may be relieved by sitting
up and leaning forward and is intensified by lying supine

PERICARDIAL FRICTION RUB “WATER BOTTE” CONFIGURATION

- may have up to three components per cardiac cycle, is high-pitched,
and is described as rasping,scratching, or grating

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: PERICARDIAL DISEASES
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

DIAGNOSIS ETIOLOGIC CLASSIFICATION

I. Infectious Pericarditis
ECHOCARDIOGRAPHY a. Viral (coxsackievirus A and B, echovirus, mumps, adenovirus,
- sensitive, specific, simple, noninvasive, may be performed at the hepatitis, HIV)
bedside, and can identify accompanying cardiac tamponade b. Pyogenic (Pneumococcus, Streptococcus, Staphylococcus,
- echo-free space between the posterior pericardium and left ventricular Neisseria, Legioenlla)
epicardium c. Tuberculous
- most widely used imaging technique since it is sensitive, specific, d. Fungal (histoplasmosis, coccidioidomycosis, Candida,
simple, and noninvasive; may be performed at the bedside; blastomycosis)
- can identify accompanying cardiac tamponade e. Other infections (syphilitic, protozoal, parasitic)

II. Noninfectious Pericarditis

a. Acute Myocardial Infarction
b. Uremia
c. Neoplasia
i. Primary tumors (benign or malignant,
mesothelioma)
ii. Tumors metastatic to pericardium (lung and
breast cancer, lymphoma, leukemia)
d. Myxedema
e. Cholesterol
f. Chylopericardium
g. Trauma
i. Penetrating chest wall
ii. Nonpenetrating
h. Aortic dissection (with leakage into pericardial sac)
i. Postirradiation
CT/MRI j. Familial Mediterranean fever
- techniques may be superior to echocardiography in detecting loculated k. Familial pericarditis
pericardial effusions, pericardial thickening, and the identification of i. Mulibrey nanism
pericardial masses l. Acute idiopathic
- may be superior to echocardiography in detecting loculated pericardial m. Whipple’s disease
effusions, pericardial thickening, and the presence of pericardial masses n. Sarcoidosis

III. Pericarditis Presumably Related To Hypersensitivity or Autoimmunity

a. Rheumatic fever
b. Collagen vascular disease (systemic lupus erythematosus,
rheumatoid arthritis, ankylosing spondylitis, scleroderma,
acute rheumatic fever, granulomatosis with polyangiitis
(Wegener’s)
c. Drug-induced (e.g. procainamide, hydralazine, phenytoin,
isoniazid, minoxidil, anticoagulants, methysergide)
d. Post-cardiac injury
i. Postmyocardial infarction (Dressler’s syndrome)
ii. Postpericardiotomy
iii. Posttraumatic

TREATMENT
- Bed rest
- Anti-inflammatory treatment with aspirin (2–4 g/d) for 1-2 weeks then
CLASSIFICATION OF PERICARDITIS tapered over several weeks, with gastric protection (e.g., omeprazole
20 mg/d)
CLINICAL CLASSIFICATION - If aspirin is ineffective, Ibuprofen (400–600 mg tid) or indomethacin
- unresponsive, colchicine (0.5 mg bid, given for 4–8 weeks) (25–50 mg
I. Acute Pericarditis (<6 weeks)
tid)
a. Fibrinous
- Glucocorticoids (e.g., prednisone 1 mg/kg per day) usually suppress the
b. Effusive (Serous or Sanguineous)
clinical manifestations of acute pericarditis in patients who have failed
therapy with the anti-inflammatory therapies
II. Subacute Pericarditis (6 weeks to 6 months)
- full-dose corticosteroids should be given for only 2–4 days and then
a. Effusive-Constrictive
tapered
b. Constrictive

III. Chronic Pericarditis (>6 months) CARDIAC TAMPONADE

a. Constrictive – accumulation of fluid in the pericardial space in a quantity sufficient to
b. Effusive cause serious obstruction of the inflow of blood into the ventricles
c. Adhesive (Nonconstrictive) results in cardiac tamponade
- Causes: idiopathic pericarditis (most common) and neoplastic disease

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: PERICARDIAL DISEASES
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

– Beck’s triad are hypotension, soft or absent heart sounds, and jugular
venous distention with a prominent x descent but an absent y descent
– 200 mL when the fluid develops rapidly or >2000 mL in slowly
developing effusions

CLINICAL MANIFESTATIONS
– Dyspnea
– Orthopnea
– Hepatic engorgement

MANAGEMENT

PERICARDIOCENTESIS

PARADOXICAL PULSE
– SBP decreases of greater than normal (10 mmHg) upon inspiration
– may be detected by palpating weakness or disappearance of the
arterial pulse during inspiration
VIRAL OR IDIOPATHIC ACUTE PERICARDITIS
DIAGNOSIS - antecedent infection of the respiratory tract,
- more common in young adults
- fever and precordial pain, often 10 to 12 days after a presumed viral
ECG illness
- reduction in amplitude of the QRS complexes, and electrical alternans - constitutional symptoms are usually mild to moderate, and a
of the P, QRS, or T waves pericardial friction rub is often audible
- abnormal T waves may persist for several years and be a source of
CHEST ROENTGENOGRAM confusion in persons without a clear history of pericarditis.
- show enlargement of the cardiac silhouette, with a “water bottle” - coxsackievirus A or B or the virus of influ-enza, echovirus, mumps, HSV,
configuration chickenpox, adenovirus, cytomegalovirus, Epstein-Barr.
- fever and precordial pain, often 10 to 12 days after a presumed viral
TRANSTHORACIC ECHOCARDIOGRAM illness
- echo-free space between the posterior pericardium and left ventricular
epicardium TREATMENT
- late diastolic inward motion (collapse) of the right ventricular free wall - bed rest and anti-inflammatory treatment with aspirin (2–4 g/d)
and the right atrium - If Ineffective: ibuprofen (400–600 mg tid), indomethacin (25–50 mg
tid), or colchicine (0.6 mg bid), is often effective.
- Glucocorticoids (e.g., prednisone, 40–80 mg daily)

CHRONIC CONSTRICTIVE PERICARDITIS

- idiopathic pericarditis
- trauma with organized blood clot
- cardiac surgery
- mediastinal irradiation
- idiopathic pericarditis
- purulent infection
- Histoplasmosis
- neoplastic disease
- rheumatoid arthritis
- SLE
- chronic renal failure with uremia treated by chronic dialysis

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: PERICARDIAL DISEASES
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

- pulse pressure is normal or reduced

- heart sounds may be distant
- an early third heart sound

DIAGNOSTICS

ECG
- low voltage of the QRS complexes and diffuse flattening or inversion of
the T waves

CHEST ROENTGENOGRAM
- shows a normal or slightly enlarged heart

TRANSTHORACIC ECHOCARDIOGRAM
- pericardial thickening, dilation of the IVC and hepatic veins, and a sharp
halt in ventricular filling in early diastole

TREATMENT
- Pericardial resection is the only definitive treatment
- Dietary sodium restriction and diuretics are useful during preoperative
preparation
- Operative mortality is in the range of 5 to 10%

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