Pericardial Disease

the visceral pericardium is a serous membrane that is

separated by a small quantity (15–50 mL) of fluid, an
ultrafiltrate of plasma, from the fibrous parietal
pericardium.
Acute Pericarditis
Most common pathologic process involving the
pericardium.
There are four principal diagnostic features:
Chest pain -it is usually present in the acute
infectious types
Pain is often absent in slowly developing
tuberculous, postirradiation, neoplastic, and uremic
pericarditis. The pain of acute pericarditis is often
severe, retrosternal and left precordial, and referred
to the neck, arms, or left shoulder.
Often the pain is pleuritic, consequent to
accompanying pleural inflammation (i.e., sharp and
aggravated by inspiration and coughing), but
sometimes it is a steady, constricting pain that
radiates into either arm or both arms and resembles
 that of myocardial ischemia; therefore, confusion
with acute myocardial infarction (AMI) is common.
Characteristically, however, pericardial pain may be
relieved by sitting up and leaning forward and is
intensified by lying supine.
A pericardial friction rub is audible in about 85% of
these patients, may have up to three components
per cardiac cycle, is high-pitched, and is described as
rasping, scratching, or grating. It is heard most
frequently at end expiration with the patient upright
and leaning forward.
The electrocardiogram (ECG)changes secondary to
acute subepicardial inflammation.
It typically evolves through four stages.
Pericardial effusion is usually associated with pain
and/or the ECG changes mentioned above.
Differentiation from cardiac enlargement may be
difficult on physical examination, but heart sounds
may be fainter with pericardial effusion. The friction
rub may disappear, and the apex impulse may vanish
 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.

Classification of Pericarditis
Clinical Classification
I. Acute pericarditis (<6 weeks)
A. Fibrinous
B. Effusive (serous or sanguineous)
II. Subacute pericarditis (6 weeks to 6 months)
A. Effusive-constrictive
B. Constrictive
III. Chronic pericarditis (>6 months)
A. Constrictive
B. Effusive
C. Adhesive (nonconstrictive)
Etiologic Classification
I. Infectious pericarditis
A. Viral
B. Pyogenic
C. Tuberculous
D. Fungal
E. Other infections (syphilitic, protozoal, parasitic)
II. Noninfectious pericarditis
A. Acute myocardial infarction
B. Uremia
C. Neoplasia
1. Primary tumors (benign or malignant, mesothelioma)
2. Tumors metastatic to pericardium (lung and breast
cancer, lymphoma, leukemia)
D. Myxedema
E. Cholesterol
F. Chylopericardium
G. Trauma
1. Penetrating chest wall
2. Nonpenetrating
H. Aortic dissection
I. Postirradiation
III. Pericarditis presumably related to hypersensitivity or
autoimmunity
A. Rheumatic fever
B. Collagen vascular disease
C. Drug-induced
D. Post-cardiac injury
Diagnosis

Echocardiography is the most widely used imaging

technique since it is sensitive, specific, simple, and
noninvasive
Echocardiography allows localization and estimation of
the quantity of pericardial fluid.
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.
may also result from bleeding into the pericardial space
after cardiac operations, trauma, and treatment of
patients with acute pericarditis with anticoagulants.
The three principal features of tamponade (Beck's triad)
are hypotension, soft or absent heart sounds, and
jugular venous distention with a prominent x descent but
an absent y descent. There are both limitation of
ventricular filling and reduction of cardiac output.
The quantity of fluid necessary to produce this critical
state may be as small as 200 mL when the fluid develops
rapidly or >2000 mL in slowly developing effusions when
the pericardium has had the opportunity to stretch and
adapt to an increasing volume.
It should be considered in any patient with otherwise
unexplained enlargement of the cardiac silhouette,
hypotension, and elevation of jugular venous pressure.
Paradoxical Pulse
This important clue to the presence of cardiac
tamponade consists of a greater than normal (10 mmHg)
inspiratory decline in systolic arterial pressure.
Thus, in cardiac tamponade the normal inspiratory
augmentation of right ventricular volume causes an
exaggerated reciprocal reduction in left ventricular
volume. Right ventricular infarction may resemble
cardiac tamponade
Paradoxical pulse occurs not only in cardiac tamponade
but also in approximately one-third of patients with
constrictive pericarditis
Diagnosis
Echocardiography
Transesophageal echocardiography may be necessary to
diagnose a loculated or hemorrhagic effusion responsible
for cardiac tamponade.

Differential Diagnosis
Pericarditis secondary to postcardiac injury
Pyogenic (purulent) pericarditis is usually secondary to
cardiothoracic operations, by extension of infection from
the lungs or pleural cavities
Pericarditis of renal failure occurs in up to one-third of
patients with chronic uremia (uremic pericarditis)
Pericarditis due to neoplastic diseases results from
extension or invasion of metastatic tumors (most
commonly carcinoma of the lung and breast, malignant
melanoma, lymphoma, and leukemia) to the
pericardium; pain, atrial arrhythmias, and tamponade are
complications that occur occasionally.
Chronic Pericardial Effusions
Tuberculosis is a common cause .
Chronic Constrictive Pericarditis
This disorder results when the healing of an acute
fibrinous or serofibrinous pericarditis or the resorption of
a chronic pericardial effusion is followed by obliteration
of the pericardial cavity with the formation of
granulation tissue. a high percentage of cases are of
tuberculous origin
Clinical and Laboratory Findings
Weakness, fatigue, weight gain, increased abdominal
girth, abdominal discomfort, a protuberant abdomen,
and edema are common.
Exertional dyspnea is common, and orthopnea may
occur, although it is usually not severe. Acute left
ventricular failure (acute pulmonary edema) is very
uncommon.
Congestive hepatomegaly is pronounced and may impair
hepatic function and cause jaundice; ascites is common
and is usually more prominent than dependent edema.
The apical pulse is reduced and may retract in systole
(Broadbent's sign). The heart sounds may be distant; an
early third heart sound
A systolic murmur of tricuspid regurgitation may be
present.
Atrial fibrillation is present in about one-third of patients.
Differential Diagnosis
Cor pulmonale- But venous pressure falls during
inspiration (i.e., Kussmaul's sign is negative).
Tricuspid stenosis -However, in tricuspid stenosis, a
characteristic murmur as well as the murmur of
accompanying mitral stenosis is usually present.
The features favoring the diagnosis of restrictive
cardiomyopathy over chronic constrictive pericarditis
include a well-defined apex beat, cardiac enlargement,
and pronounced orthopnea with attacks of acute left
ventricular failure, left ventricular hypertrophy, gallop
sounds (in place of a pericardial knock), bundle branch
block,
Tuberculous Pericardial Disease
Common cause of chronic pericardial effusion.
The clinical picture is that of a chronic, systemic illness in
a patient with pericardial effusion. It is important to
consider this diagnosis in a patient with known
tuberculosis, with HIV, and with fever, chest pain, weight
loss, and enlargement of the cardiac silhouette of
undetermined origin.