Pericardial Disease

Marshell Tendean, M,D DPCP

Department of Internal Medicine
UKRIDA Faculty of Medicine
Jakarta - Indonesia
The Anatomy of normal Pericardium
• Two major components
• Visceral pericardium mesothelial monolayer
facilitate fluid and ion exchange
• Parietal pericardium fibrocollagenous tissue
• Pericardial Fluid
• 15 - 50 ml of clear plasma ultrafiltrate
Disesase of The Pericardium
• Acute pericarditis
• Chronic pericarditis
• Pericardial cyst
• Tumor of the pericadium
Pericarditis
• Definition : Inflamation of the pericardium.
• Classification :
• Clinical classification :
• Acue
• Subacute
• Chronic
• Etiologic classification
• Infectious
• Non infectious
• Pericarditis due to autoimune disesase or hyoersensitivity
Cinical 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
II. Noninfectious pericarditis
I. Infectious pericarditis A. Acute myocardial infarction
A. Viral (coxsackievirus A and B, echovirus, B. Uremia
mumps, adenovirus, hepatitis, HIV) C. Neoplasia
1. Primary tumors (benign or malignant, mesothelioma)
B. Pyogenic (pneumococcus, streptococcus, 2. Tumors metastatic to pericardium (lung and breast cancer,
staphylococcus, Neisseria, Legionella) lymphoma, leukemia)

C. Tuberculous D. Myxedema
E. Cholesterol
D. Fungal (histoplasmosis, F. Chylopericardium
coccidioidomycosis, Candida, G. Trauma
blastomycosis) 1. Penetrating chest wall
2. Nonpenetrating
E. Other infections (syphilitic, protozoal,
H. Aortic dissection (with leakage into pericardial sac)
parasitic) I. PostirradiationJ. Familial Mediterranean fever
K. Familial pericarditis
1. 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 (systemic lupus erythematosus, rheumatoid
arthritis, ankylosing spondylitis, scleroderma, acute rheumatic fever,
granulomatosis with polyangiitis (Wegener's)
C. Drug-induced (e.g., procainamide, hydralazine, phenytoin, isoniazide,
minoxidil, anticoagulants, methysergide)
D. Post-cardiac injury
1. Postmyocardial infarction (Dressler's syndrome)
2. Postpericardiotomy
3. Posttraumatic
Most Common Etiologies of Pericarditis
Acute Pericarditis
• Clinical sympoms :
• Pericarditic chest pain “ pain
agravated upon lying position
• Pericardial rubs :
• Continous heart sound divide by 1
sistole and 2 diastole
• Ewart Sign
• Muffled heart sound
(Circulation. 2006;113:1622-1632.)
10
EKG in Pericarditis
Risk for Developing Cardiac Tamponade
(Circulation. 2006;113:1622-1632.)
15
Clinical Presentation
• Sxs
• Chest Pain, dyspnea, near-syncope
• Generally more comfortable sitting forward
• Sxs c/w the underlying cause of tamponade

• Physical Exam
• Beck’s Triad - Elev’d JVP, hypotension, dec’d heart sounds
• JVP w/ preserved x descent and dampened or absent y descent
• Generally w/ narrow pulse pressure
• Tachycardia, other signs of HF (tachypnea, diaphoresis, cool extremities, cyanosis, etc)
• Pulsus paradoxus
• Dec’d or absent cardiac impulse
• +/- Friction rub
In the incessant type, discontinuation
of or attempts to wean patients from
anti- in ammatory treatment (eg,
aspirin, indomethacin, ibuprofen)
nearly always ensure a relapse in less
than 6 weeks.
This type of relapsing or recurrent
pericarditis appears to be particularly
frequent in patients receiving
corticosteroid therapy; several studies
have shown that the mean number of
relapses was much higher in those
receiving corticosteroid therapy than
in those who were not.5,6,40 In the
intermit- tent type, patients have
symptom-free intervals of greater
than 6 weeks without treatment
Pulsus “Paradoxus”
• Dec in SBP > 10-12 mmHg w/
inspiration

• Can also occur in pts w/

COPD, pulm dz, PTX, severe
asthma

• Can have tamponade w/o

pulsus paradoxus
• In pts w/ pre-existing elev’s
in diastolic pressures and/or
volume (eg, LV dysfnx, AI and
ASD)
Features to Differentiate Tamponade, Constrictive
pericarditis, Restrictive cardiomyopathy, RVMI
Emergency Bedside Pericardiocentesis
• 16- or 18-gauge needle
inserted at angle of 30-
45° to the skin, near the
left xiphocostal angle,
aiming toward the L
shoulder
Tx of Cardiac Tamponade – Other Measures

• IVFs, especially if hypovolemic or if diuretics were given for dx of HF

• Temporary inotropic support (Dobutamine, Dopamine)

• Serial echos after draining the fluid

• Analysis of pericardial fluid

• Only has a low yield in determining the etiology of pericardial dz
• Can send for specific gravity, pH, glc, LDH, protein, cell count, cytology, staining & Cx
for bacteria, fungi, & TB).
Tx of Recurrent Effusions
• Pericardectomy

• Pericardial-peritoneal shunt

• Pericardiodesis - Steroids, tetracycline, or anti-neoplastic drugs

administered into the pericardial space  sclerosis of the pericardium
Viral or Idiopathic Pericarditis
• Coxsackievirus A or B or the virus of influenza, echovirus, mumps,
herpes simplex, chickenpox, adenovirus, cytomegalovirus, Epstein-
Barr, or HIV has been isolated from pericardial fluid and/or
appropriate elevations in viral antibody titers have been noted.
• Pericardial effusion is a common cardiac manifestation of HIV; it is
usually secondary to infection (often mycobacterial) or neoplasm,
most frequently lymphoma.
• Most frequently, a viral causation cannot be established; the
term idiopathic acute pericarditis is then appropriate.
Treatment Acute Idiopathic Pericarditis
• Acute idiopathic pericarditis there is no specific therapy, but bed rest and anti-inflammatory treatment with aspirin
(2-4 g/d) may be given.

• Colchicine may prevent recurrences, but when recurrences are multiple, frequent, and disabling; continued beyond
2 years; and are not controlled by glucocorticoids, pericardiectomy may be necessary to terminate the illness.
Colchicine
Pericardiositesis
Tuberculosis Pericarditis

Category and Criteria :

Definite tuberculous pericarditis

    Tubercle bacilli are found in stained smear or culture of pericardial fluid; and/or

    Tubercle bacilli or caseating granulomata are found on histological examination of pericardium

Probable tuberculous pericarditis

    Evidence of pericarditis in a patient with tuberculosis demonstrated elsewhere in the body; and/or

    Lymphocytic pericardial exudate with elevated ADA activity; and/or

    Good response to antituberculosis chemotherapy

Circulation. 2005;112:3608-3616
Constrictive pericarditis

J Am Coll Cardiol 2004;43:271-5
Treatment