Pericardial diseases 2020 final

By
Dr Abdelrahman Jamiel
MD, FRCP, FESC, FASE
Consultant cardiologist
KAMC Riyadh
August 2020

 Acute pericarditis
 Recurrent, Incessant and Chronic
pericarditis
 Pericardial effusion and Tamponade
 Special features of Pericarditis in
children
 Quiz

 Normal thickness - 1 to 2 mm
 Outer fibrous layer (Parietal)
 Inner serous layer (Visceral)
 In between – Pericardial space with < 50 ml
serous fluid
 The proximal segments of the great arteries
are intra-pericardial
 The Pulmonary veins are extra-pericardial

 The transverse sinus- behind the
Asc Ao and MPA and above the
roof of the LA
 The oblique sinus is located
behind the LA delineated by the
pulmonary veins and the IVC

 At end inspiration:
-6 mmHg
 At end expiration:
-3 mmHg

 No vital function
 Limits the extent of acute dilatation of the ventricles
 Lubrication - Decreasing friction
 Mechanical barrier to spread of infection

 Infectious
most often viral
or bacterial (tuberculosis)
 Noninfectious
 Renal failure
 Autoimmune diseases,
 Cancer related (Lung, lymphoma, leukemia),
 Post cardiac surgery or trauma,
 Post MI (Acute or delayed),
 Idiopathic in 80-85%

AP is diagnosed when at least two of the following:
1. Characteristic Chest pain
2. Characteristic ECG changes
3. Pericardial Friction rub
4. New or worsening pericardial effusion

Characteristic chest pain:
 Sharp
 Persistent not related to exertion
 Pleuritic, increases with respiration
 Positional - relieves when the patient leans forward and made
worse in the supine position
 Often radiates to the trapezius ridge
 and may be associated with a low grade fever or other
symptoms of viral infection

 Diffuse ST-segment elevation
(concave upward)
 PR-segment depression in lead II and
PR elevation in aVR in >60% of
cases
 In later stages, there is normalization
of ST-segment elevation, followed by
T-wave inversions and then
normalization of PR segment

 ESR and CRP are elevated in >80% of patients with AP
 Troponin may be very mildly elevated in 25% of patients usually associated with normal CKMB. When
troponin is high and without wall motion abnormalities, the diagnosis of myopericarditis should be
considered
 CXR may reveal pleural disease, cardiomegaly in case of large pericardial effusion, although it is
most often normal in AP
 Echo is essential to detect pericardial effusion and tamponade. Pericardial effusion is reported in
about 50-60%, and it is usually mild (<10 mm)
 In difficult cases, CT can show the inflamed pericardium
 Cardiac MRI can show inflamed, thickened pericardium >2 mm as well as pericardial edema and late
gadolinium enhancement

 Recurrent pericarditis: in cases of New symptoms after a
remission with a symptom-free interval of >4-6 weeks
 Incessant pericarditis: In cases of prolonged symptoms without
remission <3 months
 Chronic pericarditis: for patients with continued symptoms >3
months

Indications for admission – high risk features
 High grade fever (>38°C),
 Large pericardial effusion/Tamponade
 The use of anticoagulants
 Post Traumatic
 Evidence of myocarditis
 Immuno-compromised patient
 Lack of response to anti-inflammatory therapy
 Subacute onset

 NSAID for 2 to 4-week and taper after resolution of symptoms and CRP
normalization
 Plus Colchicine for 3 months
 This combination reduces the risk for recurrent pericarditis compared with an
NSAID alone
 Options for NSAID therapy include:
 high-dose ibuprofen (e.g., 600-800 mg every 6-8 hours)
 Aspirin (e.g., 750-1000 mg every 8 hours)
 or Indomethacin (e.g., 25-50 mg TID
 Aspirin is favored in post–myocardial infarction pericarditis

 Colchicine improves clinical response
and reduces the risk of recurrence of
pericarditis and is recommended at a
dose of 0.5-0.6 mg daily for patients
<70 kg and 0.5-0.6 mg twice daily for
>70 kg
 Colchicine recently has been shown to
be effective to reduce the incidence of
the post-pericardiotomy syndrome in
patients post cardiac surgery (COPPS
Trial)
NEJM 2013; 369:1522-9
DOI: http://dx.doi.org/10.1093/eurheartj/ehq319 2749-2754

 Corticosteroids are effective for pericarditis, but are associated with an
increased risk of recurrence
 They should not be used as first-line therapy but have specific
indications:
 Contraindications to NSAID therapy
 Failure of NSAID therapy
 Recurrences not responding to NSAID therapy
 Systemic inflammatory disease on steroids
 Pregnancy
 Renal failure
 Concomitant anticoagulant therapies Imazio et al. Circulation 2007;115:2739-44

 Additional therapeutic options to be considered after failure of triple anti-
inflammatory therapy include:
 Azathioprine
 IVIG
 and biological agents (the most common in clinical practice is Anakinra)
 Anakinra, an Interleukin-1 antagonist, Derived from E coli, is especially
indicated in patients with recurrent pericarditis:
 Steroid dependence and not able to withdraw steroids,
 Colchicine resistance (unable to control the disease with colchicine),
 Evidence of systemic inflammation (e.g., fever, CRP elevation)
 Pericarditis as a result of specific diseases should be treated according to the
primary disorder (e.g., dialysis for uraemia; antibiotics and drainage for
purulent pericarditis).

 Aspirin or NSAID plus colchicine first
 Then if the patient is still not responding or has additional
recurrences, change to a corticosteroid plus colchicine
 If additional therapy is necessary, triple therapy may be
considered with aspirin or an NSAID plus corticosteroid
plus colchicine
 In patients on steroids, it is critical to use low to
moderate doses (e.g., prednisone 0.2-0.5 mg/day or
equivalent) for 4 weeks
 Then slow tapering after symptom resolution and
normalization of CRP

 In case of recurrence of symptoms during steroid
tapering (which is very common at doses <15
mg/day of prednisone or the equivalent),
 Clinicians should not again increase the
corticosteroid but rather should try to control the
disease by increasing or reinstituting aspirin or
an NSAID plus colchicine
 Triple therapy for recurrent pericardial pain is
similar to multidrug therapy for angina, where
symptom control is achieved by a combination of
different drugs

Monitoring is essentially based on the assessment of CBC, creatinine,
CK, transaminases, CRP, and echo

Likely to progress to cardiac tamponade:
 Neoplastic diseases - 30-60% of cases
 Infections (i.e. viral: EBV, CMV enteroviruses, HIV, bacterial, especially tuberculosis)
 Iatrogenic hemopericardium
 Post-traumatic pericardial effusion
 Post-cardiotomy syndrome
 Hemopericardium in aortic dissection and rupture of the heart after acute myocardial
infarction
 Renal failure - 10-15% of cases

Rarely progressing to cardiac tamponade
 Systemic autoimmune disease - 2-6%
 Hypo- or hyperthyroidism
 Early and late pericarditis (Dressler's syndrome) in acute myocardial
infarction - 1-2%
 Others: Chylopericardium

Never progressing to cardiac tamponade
 Pericardial transudates caused by heart failure or
pulmonary hypertension
 Pericardial transudates in the last trimester of normal
pregnancy

Drugs
 Antihypertensive medications
 Anticoagulants, thrombolytics, etc. 5-10%
Injury
 Complex PCI
 Pacemaker implantation
 Endomyocardial biopsy
 Recent cardiac surgery
 Indwelling instrumentation
 Blunt chest trauma
Dehydration, diuretics (reduced circulating volume)

 Trivial seen only in systole
 Small <1.0 cm
 Moderate 1.0–2.0 cm
 Large >2.0 cm
 Very large >2.5 cm

 Up to 50 mL fluid is normal
 50 to 100 mL is mild
 100 to 500 mL is moderate
 and >500 mL is large
 The size of Pericardial effusion is correlates poorly with its
hemodynamic effect

 The rate of pericardial fluid accumulation is
critical for the clinical presentation
 If pericardial fluid is quickly accumulating,
even less than 250 ml, may cause acute
cardiac tamponade “surgical tamponade”
within few minutes
 Conversely, a slowly accumulating pericardial
fluid may allow the collection of 1000-1500 ml
within days or weeks before development of
cardiac tamponade “medical tamponade”

 Preclinical tamponade when Pericardial pressure= RA pressure but it is lower
than LA
 Initial cardiac tamponade when pericardial pressure= LA pressure
 Moderate cardiac tamponade when the pericardial pressure is>10-12 mmHg
and an abnormal JVP and signs of compression of right heart chambers can
be detected
 Advanced cardiac tamponade when further elevation of pericardial pressure
leads to significant reduction of BP and SV
 When compensatory mechanisms are exhausted, preload becomes
insufficient to sustain cardiac filling and systemic perfusion, an abrupt drop in
heart rate and blood pressure is the usual terminal event.

Elevated intra pericardial pressure
Impaired diastolic filling Elevated venous P
Reduced CO and hypotension High JVP
Tachycardia, sweating & cold extreme ties

Cardiac tamponade occurs when intrapericardial pressure is higher than intracardiac pressure and
should be suspected in patients with:
 Severe dyspnoea
 Tachypnea
 Tachycardia
 Hypotension
 Pulsus paradoxus (can be seen in marked dyspnea due to metabolic disorders, COPD, and PE)
 High JVP

Low voltage ECG, sensitivity of 42%; Electrical alternans, sensitivity of 16-21% Cardiomegaly with clear lung fields

2D and M-mode
 RA collapse
 RV diastolic collapse
 Swinging of the heart
 IVC plethora
Doppler
 Respiratory variation in MV and TV inflow
 Variation in LVOT and RVOT
 HV flow doppler

 RA collapse occurs in late diastole/early
systolic, near the peak of R wave
 It is very sensitive but not specific (86%)
 When duration of RA collapse exceeds
one-third of the cardiac cycle is nearly
100% sensitive and specific for clinical
cardiac tamponade
 RA Inversion Time Index (RAITI)
 Using 33% as the threshold Specificity
= 100% Sensitivity = 94%

 Occurs in early diastole, immediately
after closure of AV at the time of
opening of the MV (after T wave)
 Most commonly involves the RVOT
(more compressible area of RV)
 When collapse extends to the body
of the RV, the intra pericardial P is
very high
 RV collapse can be falsely negative in
RVH, PHTN, AR and ASD

 Respiratory variation: Reduced mitral
inflow during inspiration by >25% and
increased during expiration
 The opposite is right for TV inflow by
>40%
 Variation of the RVOT and LVOT flow
(pulsus paradoxus)

 IVC dilation with lack of collapsibility> 50%
during inspiration
 HV: In case of large PE - predominant
systolic and decreased diastolic forward flow
because ventricular ejection reduces
intrapericardial pressure and allows cardiac
filling
 In tamponade:
 Diastolic forward flow disappears
 Systolic forward flow is observed only during
inspiration
 Increased diastolic flow reversal in hepatic vein;
has high positive (82%) and negative predictive
values (88%) for cardiac tamponade

Sign Sensitivity Specificity
RA Diastolic collapse 50-100% 33-100%
RV Diastolic collapse 48-100% 72-100%
IVC plethora 97% 40%

 Patients diagnosed with a large pericardial effusion and minimal or no
evidence of hemodynamic compromise may be treated conservatively with:
 Careful hemodynamic monitoring and serial echo
 Fluid resuscitation
 Avoidance of diuretics and vasodilators
 Treatment of underlying cause
Mechanical ventilation should be avoided whenever possible
 Effusions that progressively enlarge, that lead to worsening symptoms
suggesting cardiac tamponade, or refractory to a conservative approach
should be treated with pericardiocentesis

 Pericardiocentesis can be performed under fluoroscopic or
echocardiographic guidance
 The apical approach was utilized in two-thirds, while the subxcostal was
ideal in only 15%
 An indwelling pericardial catheter with intermittent or continuous suction
is left in the pericardial space until the rate of fluid return is negligible
(<25 ml/d)

 Surgical pericardiotomy and drainage is often preferred in the following:
 Recurrent effusion that has loculated
 Pericardial biopsy is desired
 Purulent pericarditis is suspected
 Hemopericardium from aortic dissection
 Postinfarction rupture of the LV free wall, or trauma is present
 If the patient has a coagulopathy
For both chronic and recurrent effusions, the 2015 ESC Guidelines recommend
surgical pericardiectomy only in patients with symptomatic effusions in whom
medical therapy and repeated pericardiocentesis were not successful

 Pericarditis accounts for <0.2% of the emergency visits of children without
prior heart disease presenting with chest pain to a tertiary pediatric
emergency setting
 There is a changing trend of the underlying etiology of pediatric pericarditis,
with infectious pericarditis becoming uncommon and post-cardiotomy
syndrome being a major underlying etiology
 In a large database study of hospitalized pediatric patients with pericarditis
and pericardial effusions, post-cardiac surgery (54%), neoplasia (13%), renal
(13%), idiopathic or viral pericarditis (5%) and rheumatologic (5%) were the
major underlying etiologies
 Post-cardiotomy syndrome is common after surgical closure of secundum
atrial septal defects (ASD), with incidence as high as 28%
 ASD closure is also a risk factor for recurrent pericarditis, which is fortunately
uncommon in childhood but can have a long protracted course with frequent
recurrences

 Post-cardiotomy syndrome tends to occur within 1-2 weeks of the surgery
 Infants and young children tend to be fussy and have decreased feeding with tachycardia being an
important physical sign
 Chest pain is rarely due to an underlying primary cardiac etiology in children, but the characteristics of
the pain along with EKG changes and inflammatory markers might be helpful
 Non-steroidal anti-inflammatory drugs (NSAID) are most frequently used to treat childhood
pericarditis, with the use of colchicine restricted to few centers
 The European Society of Cardiology (ESC) recommends high dose NSAIDs as the first line therapy
for pediatric pericarditis, with colchicine as a second line therapy
 A recently completed systematic review demonstrated lack of evidence to support or discourage the
use of colchicine in pediatric pericarditis
 In adult and pediatric patients with refractory recurrent pericarditis, there is now multiple studies
demonstrating safety and efficacy of interleukin-1 receptor antagonists such as anakinra
 In selected patients, pericardiectomy can also be safely performed in childhood for refractory
pericarditis with excellent outcome

Echo of a patient with this ECG
is most likely to show:
A. Pacemaker lead in RV
B. RWMA
C. Global hypokinesis
D. Hyperdynamic LV
E. Small pericardial effusion

Echo of a patient with this ECG is most
likely to show:
A. Pacemaker lead in RV
B. RWMA
C. Global hypokinesis
D. Hyperdynamic LV
E. Small pericardial effusion

When you will say the patient has:
 Recurrent pericarditis?
 Incessant pericarditis?
 Or Chronic pericarditis???

A 26 y o male
Chest pain gets worse with inspiration and supine position, not related to exertion
URTI 2 weeks ago
On examination: Afebrile, BP 118/70 mm Hg, HR 70 bpm
Lungs are clear
An intermittent pericardial rub is noted
Chest X-ray is normal
ECG: sinus rhythm, Diffuse ST elevation
Which of the following is the most appropriate therapeutic strategy at this time?
a. Ibuprofen for 8-12 weeks; colchicine for 1-2 weeks.
b. Prednisone for 8-12 weeks; colchicine for 1-2 weeks.
c. Oxycodone for 1-2 weeks; prednisone for 8-12 weeks.
d. Ibuprofen for 1-2 weeks; colchicine for 8-12 weeks.
e. Prednisone for 1-2 weeks; oxycodone for 8-12 weeks.

Which of the following statement is correct regarding the
Colchicine?
1- It reduces the recurrence only after recurrent pericarditis
2- Effect is not attenuated by pretreatment with corticosteroids
3- It reduces the incidence of post pericardioctomy syndrome
4- It is contraindicated in patients with collagen vascular disease

A 20-year-old male
1-week history of rhinitis, myalgia, fever, and chest pain
His examination- pericardial rub, otherwise is unremarkable
Which of the following agents may contribute to an increased risk of
recurrent pericarditis?
a. Aspirin
b. Ibuprofen
c. Corticosteroids
d. Colchicine
e. Indomethacin

How much do you know about Kineret (Anakinra)?
a- Derived from streptococcus
b- Interleukin-1 antagonist
c- An experimental medication
d- I have no idea

A 45-year-old man
-Sudden cardiac arrest at his workplace
-Successfully cardioverted by AED which recorded VT
-Hospital work up reveals a nonischemic DCM
-After treatment of HF he received an ICD
-That night you are called because BP has dropped and his HR has increased
-He complains of chest tightness and SOB
-He has clear lungs, but his JVP is elevated
-His ECG shows no ischemic patterns
-An echocardiogram reveals a small pericardial effusion
-You transfered him to the ICU and place a central venous catheter and you got
the RA pressure tracing below

Which of the following is the most appropriate next step?
a. Pericardiocentesis
b. Thrombolytic therapy
c. Blood transfusion
d. Aggressive diuresis
e. Surgical pericardial window

RA collapse occurs during:
A. Early Diastole
B. Mid Diastole
C. Late diastole
D. Mid systole

RV diastolic collapse occurs during:
A. Early diastole
B. Mid Diastole
C. Late Diastole
D. No idea

Normal thickness of parietal pericardium:
A. 5-6 mm
B. < 4 mm
C. < 2 mm
D. No idea

Pericardial diseases 2020 final

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Pericardial diseases 2020 final

Similar to Pericardial diseases 2020 final (20)

Recently uploaded

Recently uploaded (20)

Pericardial diseases 2020 final