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: Test:
 * 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
 * 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