PERICARDIAL DISEASES

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PERICARDIAL DISEASES

• OLOWOLAFE A.M.
• OLUMIDE O.

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OUTLINE

• Introduction
• Presentations
• Acute Pericarditis
• Pericardial Effusion Cardiac Tamponade
• Constrictive pericarditis

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INTRODUCTION

• The pericardium serves to
• Lubricate the surface of the heart
• Prevent deformity and dislocation of the heart
• Acts as a barrier to the spread of infections
• Maintain normal ventricular compliance

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BRIEF ANATOMY

• The pericardium is the protective covering of the
  heart and it has two layers
• inner visceral pericardium
• outer parietal pericardium.
• The visceral pericardium reflects back upon
  itself at the level of the great vessels to join
  the parietal pericardium, forming a sac which
  contains fluid (about 50ml)

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ACUTE PERICARDITIS
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ACUTE PERICADITIS

• Inflammation of the pericardium.
• The most common pericardial disease with
  incidence of
• 16 in postmortem studies
• 0.1 of hospitalized patients
• 5 of patients seen in emergency departments with
  chest pain but no myocardial infarction (MI)
• There is deposition of fibrinous material into
  the pericardial space often with associated
  pericardial effusion.
• In many cases, it is idiopathic.

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CAUSES OF ACUTE PERICARDITIS

• Infectious pericarditis
• Viral, bacterial, TB, fungal, amoeba
• Post-myocardial infarction pericarditis
• Acute MI (early)
• Dresslers syndrome (late)
• Malignant pericarditis
• 1 (mesothelioma)
• 2 (metastatic)
• Direct extension from adjoining tumour

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CAUSES contd

• Uraemic pericarditis
• Myxoedematous pericarditis
• Chylopericardium
• Autoimmune pericarditis
• SLE
• Rheumatoid fever
• Drug-induced(procainamide, hydralazine, INH,
  doxorubicin, cyclophosphamides)
• Post-radiation pericarditis

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CAUSES contd

• Post-surgical pericarditis
• Postpericardiotomy syndrome
• Post-traumatic pericarditis
• Familial idiopathic pericarditis

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VIRAL PERICARDITIS

• The most common viral organisms are Coxsackie B
  virus Echovirus.
• Usually painful but has a short time course
  rarely long term effects
• HIV is now implicated in the cause of
  pericarditis

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POST-MYOCARDIAL INFARCTION PERICARDITIS

• Seen in about 20 of patients in the first few
  days following myocardial infarction.
• Pericarditis may occur in the recovery phase
  (2-10 weeks post-infarct) by an autoimmune
  response to cardiac damage. This is called
  Dresslers syndrome.
• Seen more in anterior with high cardiac enzymes
  incidence is reduced by thrombolysis.

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URAEMIC PERICARDITIS

• Results from irritation of the pericardium by
  accumulating toxins.
• Can occur in 6-10 of patients with advanced
  renal failure if dialysis is delayed.
• It is an indication for urgent dialysis because
  of the associated morbidity mortality.

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BACTERIAL PERICARDITIS

• Occurs rarely and associated with septicaemia or
  pneumonia
• May arise from an early post-operative infection
  after surgery or trauma
• May complicate endocarditis
• Staph aureus is a frequent cause of purulent
  pericarditis in HIV patients. This is fulminant
  often fatal.

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BACTERIAL contd

• Diagnosis is based on serology of pericardial
  fluid identification of organisms in pericardial
  or myocardial biopsies

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TUBERCULOUS PERICARDITIS

• Usually presents with chronic low-grade fever,
  particularly in the evening, associated with
  features of acute pericarditis, dyspnoea,
  malaise, night sweats weight loss.
• Diagnosis is usually made by pericardial
  aspiration.
• Constrictive pericarditis is a frequent outcome

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FUNGAL PERICARDITIS

• A common complication of endemic fungal
  infections by Histoplasmosis Coccidiodomycosis
• May also be caused by Candida albicans,
  especially in immunocompromised patients, drug
  addicts or after cardiac surgery.

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MALIGNANT PERICARDITIS

• Carcinoma of the bronchus, carcinoma of the
  breast Hodgkins lymphoma are the most common
  causes.
• Leukaemia malignant melanoma are also
  associated with pericarditis.
• Typically, there is a substantial pericardial
  effusion (often haemorrhagic) due to the
  obstruction of the lymphatic drainage from the
  heart.

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MALIGNANT contd

• Pericardial effusion (serous or haemorrhagic)
  pericardial fibrosis may result from radiation
  and therapy for thoracic tumours
• Absence of neoplastic cells in the pericardial
  fluid in these conditions often helps diagnosis

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CLINICAL FEATURES

• Sharp central chest pain exacerbated by movement,
  respiration, swallowing lying down but
  typically relieved by sitting forward.
• Pain may be referred to the neck and shoulders
• Pericardial friction rub (the classical sign)
• occurs in three phases corresponding to atrial
  systole, ventricular systole ventricular
  diastole (may also be a biphasic rub)

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CLINICAL FEATURES contd

• The rub is best heard with the diaphragm of the
  stethoscope at the lower left sternal edge at the
  end of expiration with the patient leaning
  forward.
• Low-grade fever
• Also include some features of pericardial effusion

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INVESTIGATIONS

• ECG (diagnostic)
• PR interval depression
• saddle-shaped (concave-upwards) ST elevation
• T wave flattening/inversion.
• Sinus tachycardia may result from fever or
  haemodynamic embarrassment

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INVESTIGATIONS contd

• Cardiac enzymes- may be elevated if myocarditis
  is associated
• Leucocytosis or Lymphocytosis
• Chest X-ray little value in
• Echocardiogram uncomplicated acute
• Radionucleotide scans pericarditis

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TREATMENT

• Oral NSAIDs
• Bed rest
• Corticosteroids- may require long term use
• Treat the cause if found
• Colchicine
• Azathioprine
• Pericardiectomy

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DIFFERENTIAL DIAGNOSIS

• Angina
• Pleurisy

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PERICARDIAL EFFUSION CARDIAC TAMPONADE
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• Pericardial effusion is a collection of fluid
  within the potential space of the pericardial
  sac. It commonly accompanies an episode of acute
  pericarditis.
• Ventricular filling may be compromised leading to
  embarrassment of the circulation, when a large
  volume collects in the pericardial space. This is
  called Cardiac tamponade.

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Aetiology

• Inflammation from infection, immunologic process.
• Trauma causing bleeding in pericardial space.
• Noninfectious conditions
• Increase in pulmonary hydrostatic pressure e.g.
  congestive heart failure.
• Increase in capillary permeability e.g.
  hypothyroidism
• Decrease in plasma oncortic pressure e.g.
  cirrhosis.
• Decreased drainage of pericardial fluid due to
  obstruction of thoracic duct
• Malignancy
• Damage during surgery.

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CLINICAL FEATURES

• Symptoms of pericardial effusion usually reflect
  the underlying pericarditis.
• These can be found on examination
• Heart sounds are soft distant
• Apex beat is usually obscured
• Friction rub in early stage. This becomes quieter
  as fluid accumulates.

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Clinical features contd

• Effusion may compress left lung base, producing
  an area of dullness to percussion below the angle
  of the left scapula (Ewarts sign)
• Compression symptoms
• Dysphagia
• Dyspnoea
• Hoarseness
• Hiccups

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Clinical features contd

• Signs of cardiac tamponade may be present
• Rise in JVP
• Pulsus paradoxus
• Reduced cardiac output
• Small quiet heart
• Raised JVP with sharp rise y descent
  (Friedreichs sign)
• Becks triad

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Investigations

• ECG
• low voltage QRS complex
• Alternating QRS complex (to fro)
• Chest x-ray
• large globular or pear shaped heart with sharp
  outlines. Usually, the pulmonary veins are hot
  distended.
• Echocardiography- most useful
• MRI

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Investigations contd

• Pericardiocentesis (diagnostic)
• removal of pericardial fluid with aseptic
  techniques under echocardiograhy guidance.
  Indicated in suspicion of tuberculous , malignant
  or purulent effusion.
• Pericardial biopsy may be needed in TB
• Others- blood culture, autoantibody screen.

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Treatment

• Treat underlying cause. Most pericardial effusion
  would resolve spontaneously but when the
  collection occurs rapidly, cardiac tamponade may
  result.
• Pericardiocentesis (therapeutic)
• Pericardial fenestration- for recurrent effusion,
  usually due to malignancy

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DIFFERENTIAL DIAGNOSIS

• Pulmonary embolism
• Pneumonia
• Aortic dissection

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CONSTRICTIVE PERICARDITIS
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Constrictive pericarditis

• Progressive thickening, fibrosis, and
  calcification of the pericardium
• These pericardial changes may not cause any
  symptoms but if the pericardium becomes so
  inelastic as to interfere with diastolic filling
  of the heart, constrictive pericarditis is said
  to have developed

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Aetiology

• TB pericarditis
• Rheumatoid arthritis
• Haemopericardium
• Viral/Purulent pericarditis
• Late manifestation after open heart surgery

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Constrictive pericarditis

• These changes occur over a considerable time,
  allowing the body to compensate unlike cardiac
  tamponade which is life threatening.
• In the later stages of constrictive pericarditis,
  the subepicardial layers of myocardium may
  undergo fibrosis, atrophy calcification.

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Clinical features

• Reduced ventricular filling- Kussmauls sign.
• Reduced cardiac output- fatigue, rapid low-vol
  pulse (hypotension reflex tachycardia)
• Systemic venous congestion- ascites, dependent
  oedema, hepatomegaly, raised JVP
• Rapid ventricular filling- pericardial knock
  heard in early diastole at the left lower sternal
  border
• Atrial dilatation(about 30 have atrial
  fibrillation)
• Pulmonary venous congestion(less commonly)-
  dyspnea, cough, orthopnea, PND

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Investigations

• Chest x-ray shows a relatively small heart in
  view of heart failure. Pericardial calcification
  (up to 50) which may be seen on lateral view.
  Not all calcified pericardium is constrictive.
• ECG- low voltage QRS complex with generalised T
  wave flattening or inversion.
• Echocardiography- thickened calcified pericardium
  and small ventricular cavities with normal wall
  thickness. Doppler may be useful.

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Investigation contd

• CT MRI- to assess pericardial anatomy and
  thickness(3mm)
• Endomyocardial biopsy-to distinguish from
  restrictive cardiomyopathy in difficult cases.
• Cardiac catheterisation- end diastolic pressure
  is usually equal in both ventricles due to
  pericardial constriction.

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Treatment

• Complete resection of the pericardium. This
  should be done as early as possible to avoid
  complication that may arise from severe
  constriction myocardial atrophy.

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Differential diagnosis

• Restrictive cardiomyopathy
• Cardiac tamponade

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