Pericardial Disease

15e – Pericardial disease

Acute pericarditis:

• Inflammation of pericardium which may be primary or secondary to systemic diseases
• Causes :

1. Viruses (coxsackie, flu, EBV, mumps, varicella, HIV)
2. Bacteria (pneumonia, rheumatic fever, TB)
3. Fungi
4. Myocardial infarction
5. Others: uremia, Rheumatoid arthritis, SLE, myxedema, trauma, surgery, malignancy, radiotherapy

Clinical feature:

• Central chest pain worse on inspiration or lying flat – relieved by sitting forward
• Pericardial friction rub may be heard
• Look for evidence of pericardial effusion or cardiac temponade
• Fever may occur

Test:

• ECG – classically shows concave (saddle-shaped) ST segment elevation, non spec
• Blood test – FBC, ESR, U&E, cardiac enzymes, viral serology, blood cultures, TFT
• ECHO

'Treatment:

• Analgesia – ibuprofen
• Treat the cause
• Consider colchicine before steroids/immunosuppressant

Pericardial effusions:

• Accumulation of fluid in the pericardial sac
• Cause : any cause of pericarditis
• Clinical pictures:
• Dyspnea, raised JVP, bronchial breathing, look for sign of cardiac tamponade

Diagnosis:

• CXR – enlarged, globular heart
• ECG – low voltage QRS complexes and alternating QRS morphologies
• ECHO – echo-free zone surrounding the heart

Management:

• Treat the cause
• Pericardiocentesis may be diagnostic or therapeutic
• Send pericardial fluid for culture, ZN stain/TB culture, cytology

Constrictive pericarditis:

• The heart is encase in rigid pericardium
• Causes: often unknown – TB or after any pericarditis
• Clinical pictures:

1. Often RHF with increase JVP, Kaussmaul sign
2. Soft, diffuse apex beat, quiet heart sound
3. Diastolic pericardial knock
4. Hepatosplenomegaly, ascites, edema

Test:

• CXR – small heat +/- pericardial calcification
• ECHO
• Cardiac catheterization

Management : surgical excision

Cardiac tamponade:

• Accumulation of pericardial fluid raises intra-pericardial pressure, hence poor ventricular filling and fall in cardiac output
• Causes:

1. Any pericarditis
2. Aortic dissection
3. Heamodialysis
4. Warfarin
5. Traseptal puncture at cardian catheterization
6. Post cardiac biopsy

Sign:

• Pulse increase, bp decreases, pulsus paradoxus, JVP increases, kaussmaul’s sign,
• Muffled S1&S2

Diagnosis:

• Beck’s triad: falling bp, rising JVP, small, quiet heart
• Big globular heart ( if > 250ml fluid)
• ECG – low voltage QRS +/- electrical alternans
• ECHO – diagnostic, echo-free zone around the heart, diastolic collapse of RA&RV

Management :

• Seek expert help
• Urgent drainage
• Send fluid for culture, ZN stain/TB culture and cytology

References

• OHCM – Cardiovascular medicine, page 140
• OHCM – practical procedure, pericardiocentesis, page 761