Pericarditis a discussion

1. Pericarditis
Frank Meissner, MD, FACP, FACC, FCCP

2. EKG-
Lead V5

3. EKG-
Lead V1

4. CVP Tracing- Tamponade
a
wave
descent
x
v y

5. Pericardial Disease
●Pericardium has fibrous parietal outer layer
and a serous visceral inner layer composed of
mesothelial cells.
●Pericardial space formed by the visceral and
parietal layers normal contains about 50 cc of
clear fluid.

6. Pericardium-functions
●Fix the heart anatomically
●Reduction of friction between the heart and the
surrounding organs.
●Barrier against the extention of
infection/malignancy.
●Distribution of hydrostatic forces on the heart.
●Prevention of acute cardiac dilatation.
●Diastolic coupling of the ventricles.

7. Major Clinical Syndromes
●Acute Pericarditis-inflammation of the
pericardium.
●Pericardial Effusion-accumulation of excess
fluid in the pericardial space
●Cardiac tamponade.
●Constrictive Pericarditis-pericardium becomes
thickened, fibrotic, and adherent

8. Specific Etiologies
Infectious:
●viral pericarditis
●tuberculous pericarditis
●bacterial pericarditis
●fungal pericarditis

9. Specific Etiologies
Noninfectious:
●Post myocardial infarction
●Uremia
●Neoplasia
●Radiation
●Immunologic-Dressler’s

10. Acute Pericarditis
Inflammation of the pericardium
chest pain, pericardial friction rub, and ECG
changes.
Most common causes:
idiopathic viral
uremia bacterial
acute MI post pericardiotomy
tuberculosis neoplasm
trauma

11. Acute Pericarditis
●Pericarditis is more common in males than
females
●Increased PMNS, increased pericardial
vascularity, increased fibrin deposition
History:
●Chest pain most common complaint
●Dyspnea-shallow breathing to avoid pain
●Differentate from ischemic chest pain

12. Acute Pericarditis
●Pericardial friction rub is pathognomonic.
●Scratching, grating, high-pitched sound. “the
squeak of leather of a new saddle under the
rider.”
●Three components: atrial systole, ventricular
systole, and rapid ventricular filling in early
diastole.
●Evanescent.

13. Acute Pericarditis: EKG Stages
● ST segment elevation in all leads except aVR, V1 often
associated with PR depression--hours
● ST segments return to baseline with T wave
flattening--days
● T wave inversion--days
● T waves revert to normal--weeks to months
● Stage 4 may persist indefinitely TB, uremia, neoplastic
disease
● Tachycardia is common

14. Acute Pericarditis: Management
●Treat underlying problem
●Bedrest
●ASA, indocin
●Refractory cases prednisone 60-80 mg/day
●Anticoagulants not administered acute phase

15. Pericardial Effusion
●Accumulation of excessive fluid in the
pericardial space
●Develops as a response to all causes acute
pericarditis
●Absolute volume and rate of accumulation
important in the development of symptoms
●Characteristics of pericardium also important

16. Pericardial Effusion: History
●May be asymptomatic
●Occasional dull chest pressure
●Symptoms from compression
○dysphagia from esophageal compression
○cough from tracheal/bronchial compression
○hiccups from phrenic nerve
○hoarseness recurrent laryngeal nerve
involvement

17. Pericardial Effusion: Findings
●Decreased heart sounds, rales
●CXR: Globular, water-bottle shape heart
●ECG: Low volts, electrical alternans
●Management: Stable effusions require only
observation and the avoidance of
anticoagulants

18. Quiz
Each of the following is a potential cause of constrictive
pericarditis except:
A. myxedema
B. tuberculosis
C. rheumatoid arthritis
D. mediastinial irradiation
E. viral infection

19. Quiz
The following are true regarding physical examination in
patients with acute pericarditis except:
A. Pericardial friction rub is pathognomonic of acute
pericarditis.
B. The presystolic component is the loudest and most easily
heard.
C. Single-component rub is more likely to occur in patients
with atrial fibrillation.
D. Exercise may help establish the presence of a classic
three-component rub.

20. Quiz
True statements about acute pericarditis include the
following except:
A. Acute pericarditis may not be clinically apparent.
B. Viral and uremic pericarditis are common forms of the
disorder.
C. The chief complaint is often chest pain.
D. Few pathological changes are noted in acute pericarditis.
E. Acute pericarditis may be associated with dyspnea.

21. Quiz
A 65 y/o man with DM, HTN, ESRD experiences severe
dyspnea towards the end of a 3 hour dialysis session. On
exam he is hypotensive with elevated neck veins and
pulsus paradoxicus. BP is unresponsive to fluids. Routine
labs are nondiagnostic. What is your next step?
A. STAT CXR
B. STAT ECG
C. STAT Blood transfusion
D. Blood cultures
E. STAT cardiac echo

22. Cardiac Tamponade: Definition
Accumulation of pericardial fluid resulting in
elevated intrapericardial pressures producing :
(1) elevation of intracardiac pressures
(2) progressive limitation of ventricular diastolic
filling
(3) reduction of stroke volume and cardiac
output.

23. Cardiac Tamponade: Clinical
●Decreased systemic arterial pressure
●small, quiet heart
●elevated jugular venous pressure
●neck veins-prominent x descent with reduced y
descent
●tachypnea, tachycardia, pulsus paradoxicus

24. Pulsus Paradoxicus
●Inspiratory decrease systemic BP>10 mm Hg
●Total Paradox in severe tamponade
●Not specific for tamponade
○COPD
○constrictive pericarditis
○restrictive cardiomyopathy
○large pulmonary embolism
●Echo is diagnostic procedure of choice
●Urgent/Emergent pericardiocentesis

25. Constrictive Pericarditis
●Constrictive pericarditis usually occurs after
episode of acute pericarditis
●Fibrin deposition results in fibrotic, thickened,
adherent pericardium
●Restricts diastolic filling of the heart
●Calcium deposition occurs in chronic stages,
●Contributes to pericardial thickening/stiffening

26. Constrictive Pericarditis: Pathophysiology
●Restricted diastolic filling all cardiac chambers
●Equalization of diastolic pressures
●Filling of the ventricles occurs in early diastole
●Dip-and-plateau pressure tracings in both
ventricles
●Elevated neck veins prominent y descent often
with significant x descent as well, producing a
W or M pattern

27. Constrictive Pericarditis
●Kussmaul’s sign
○inspiratory increase in systemic venous &
right atrial pressure
●DDX
○RVMI, RV failure
○Does not occur in cardiac tamponade
●Pulsus paradoxicus may occur is less common
than with tamponade

28. Constrictive Pericarditis
●Tuberculosis formerly leading cause worldwide
●Quite common in 3rd world countries
●Idiopathic most common etiology in the US
●Mediastinal XRT
●Cancer

29. Constrictive Pericarditis
●Decreased CO results in fatigue, weight loss,
muscle wasting
●Findings suggestive of right heart failure with
lower extremity edema, abdominal swelling,
hepatic congestion with hepatomegaly, ascites
●Distended neck veins
●Pericardial knock on auscultation

30. Constrictive Pericarditis
●CXR-pericardial calcifications
●ECG-low volts
●ECHO-doppler findings suggesting constrictive
physiology
●CT/MRI-demonstrate pericardial thickening
●Surgical excision of the pericardium.

31. Effusive-Constrictive Pericarditis
●Pericardial effusion in presence of visceral
pericardial constriction
●Hallmark is persistent elevation of right atrial
pressures despite removal of pericardial fluid
●Exam findings suggests tamponade
●After pericardiocentesis, findings consistent
with constriction
●Treatment pericardiectomy

32. Post MI Syndrome (Dressler’s)
●Autoimmune: fever, pericarditis, pleuritis
●Developed 1 wk to several months post MI
●Probably results from the development of
antiheart antibodies
●Dramatic response to antiinflammatory agents
●High recurrence rate
●Constrictive pericarditis is a complication
●Avoid anticoagulants

33. Postpericardiotomy Syndrome
●Fever, pericarditis, pleuritis developing > 1
week post cardiac surgery
●Occurs in 10 to 40% following surgery more
frequent in children (> 2 y/o).
●Autoimmune etiology similar to Dressler’s
●RX with antiinflammatory agents
●Cardiac tamponade/constriction possible