For the Final MBBS student

1. ““He who studies medicine withoutHe who studies medicine without
books sails an uncharted sea, but hebooks sails an uncharted sea, but he
who studies medicinewho studies medicine without patientswithout patients
does not go to sea at all.”does not go to sea at all.”
- Sir William Osler- Sir William Osler

2. PERICARDIALPERICARDIAL
DISEASEDISEASE

3. INTRODUCTIONINTRODUCTION
 The pericardium acts as aThe pericardium acts as a protective coveringprotective covering for thefor the
heart.heart.
 It consists of two separate layers, theIt consists of two separate layers, the inner visceralinner visceral
pericardium and thepericardium and the outer parietalouter parietal pericardium.pericardium.
 The visceral pericardium reflects back upon itself atThe visceral pericardium reflects back upon itself at
the level of the great vessels to join the parietalthe level of the great vessels to join the parietal
pericardium, thus forming a sac.pericardium, thus forming a sac.
 TheThe pericardial sacpericardial sac contains up to 50 mL ofcontains up to 50 mL of
pericardial fluid in the normal heart.pericardial fluid in the normal heart.

5. 3 presentations3 presentations of pericardial disease:of pericardial disease:
 acute pericarditisacute pericarditis
 pericardial effusion and cardiac tamponadepericardial effusion and cardiac tamponade
 constrictive pericarditis.constrictive pericarditis.

6. Acute pericarditisAcute pericarditis
 This refers to acute inflammation of theThis refers to acute inflammation of the
pericardium.pericardium.
 Classically, fibrinous material is deposited intoClassically, fibrinous material is deposited into
the pericardial space and pericardial effusionthe pericardial space and pericardial effusion
often occurs.often occurs.

7. Aetiology of pericarditisAetiology of pericarditis
I. Infectious pericarditisI. Infectious pericarditis
Viral, Bacterial, Tuberculous, FungalViral, Bacterial, Tuberculous, Fungal
II.Post-myocardial infarction pericarditisII.Post-myocardial infarction pericarditis
Ac. myocardial infarction (early)Ac. myocardial infarction (early)
Dressler's syndrome (late)Dressler's syndrome (late)
III.Malignant pericarditisIII.Malignant pericarditis Primary tumours ofPrimary tumours of
the heart (mesothelioma), Metastaticthe heart (mesothelioma), Metastatic
pericarditispericarditis

8. IV.Uraemic pericarditisIV.Uraemic pericarditis
V.Myxoedematous pericarditisV.Myxoedematous pericarditis
VI.ChylopericardiumVI.Chylopericardium
VII.Autoimmune pericarditisVII.Autoimmune pericarditis
Collagen-vascular disorders, Drug-inducedCollagen-vascular disorders, Drug-induced
VIII.Post-radiation pericarditisVIII.Post-radiation pericarditis
IX.Post-surgical pericarditisIX.Post-surgical pericarditis
X.Post-traumatic pericarditisX.Post-traumatic pericarditis
XI.Familial and idiopathic pericarditisXI.Familial and idiopathic pericarditis

9. Clinical features of Acute PericarditisClinical features of Acute Pericarditis
SymptomSymptom
 Pericardial inflammation produces sharpPericardial inflammation produces sharp
centralcentral chest painchest pain exacerbated by movement,exacerbated by movement,
respiration and lying down.respiration and lying down.
 It is typically relieved by sitting forward.It is typically relieved by sitting forward.
 It may be referred to the neck or shoulders.It may be referred to the neck or shoulders.

10. SignSign
- pericardial- pericardial friction rubfriction rub occurring in three phasesoccurring in three phases
corresponding to atrial systole, ventricular systole andcorresponding to atrial systole, ventricular systole and
ventricular diastole.ventricular diastole.
-It may also be heard as a biphasic 'to and fro' rub.-It may also be heard as a biphasic 'to and fro' rub.
-The rub is heard best with the diaphragm of the-The rub is heard best with the diaphragm of the
stethoscope at the lower left sternal edge at the end ofstethoscope at the lower left sternal edge at the end of
expiration with the patient leaning forward.expiration with the patient leaning forward.

11. InvestigationsInvestigations
 ECGECG is diagnostic.is diagnostic.
 There is concave-upwards (saddle-shaped) STThere is concave-upwards (saddle-shaped) ST
elevationelevation
 The early ECG changes must be differentiatedThe early ECG changes must be differentiated
from ST elevation found in myocardialfrom ST elevation found in myocardial
infarction.infarction.

13. TreatmentTreatment
 If a cause is found, this should be treated.If a cause is found, this should be treated.
 Bed rest and oral NSAIDs are effective inBed rest and oral NSAIDs are effective in
most patients.most patients.
 Corticosteroids have been used when theCorticosteroids have been used when the
disease does not subside rapidly, but they aredisease does not subside rapidly, but they are
associated with side-effects.associated with side-effects.

14.  If pericarditis persists for 6-12 monthsIf pericarditis persists for 6-12 months
following the acute episode, it is consideredfollowing the acute episode, it is considered
chronic.chronic.
 If the pericardium thickens and restrictsIf the pericardium thickens and restricts
ventricular filling, constrictive pericarditis isventricular filling, constrictive pericarditis is
said to have developed.said to have developed.

15. Pericardial effusion and cardiacPericardial effusion and cardiac
tamponadetamponade
 A pericardial effusion is a collection of fluidA pericardial effusion is a collection of fluid
within the potential space of the serouswithin the potential space of the serous
pericardial sac,pericardial sac,
 Commonly accompanies an episode of acuteCommonly accompanies an episode of acute
pericarditis.pericarditis.

16. Clinical Features of Pericardial EffusionClinical Features of Pericardial Effusion
 Heart sounds are soft and distant.Heart sounds are soft and distant.
 Apex beat is commonly obscured.Apex beat is commonly obscured.
 A friction rub may be evident due toA friction rub may be evident due to
pericarditis in the early stages, but thispericarditis in the early stages, but this
becomes quieter as fluid accumulates.becomes quieter as fluid accumulates.

17.  As the effusion worsens, signs of cardiacAs the effusion worsens, signs of cardiac
tamponade may become evident:tamponade may become evident:
 raised jugular venous pressure with sharpraised jugular venous pressure with sharp yy descentdescent
(Friedreich's sign)(Friedreich's sign)
 Kussmaul's sign (rise in JVP/increased neck veinKussmaul's sign (rise in JVP/increased neck vein
distension during inspiration)distension during inspiration)
 pulsus paradoxuspulsus paradoxus
 reduced cardiac output.reduced cardiac output.

18. InvestigationsInvestigations
 ECGECG reveals low-voltage QRS complexes.reveals low-voltage QRS complexes.
 Chest X-rayChest X-ray shows large globular or pear-shapedshows large globular or pear-shaped
heart with sharp outlines.heart with sharp outlines.
 EchocardiographyEchocardiography the most useful technique forthe most useful technique for
demonstrating the effusion and looking for evidencedemonstrating the effusion and looking for evidence
of tamponade.of tamponade.
 MRIMRI should be considered if haemopericardiumshould be considered if haemopericardium
(blood in the pericardial space) or loculated(blood in the pericardial space) or loculated
pericardial effusions are suspected.pericardial effusions are suspected.

20.  Pericardiocentesis -Pericardiocentesis - indicated when aindicated when a
tuberculous, malignant or purulent effusion istuberculous, malignant or purulent effusion is
suspected.suspected.
 Pericardial biopsyPericardial biopsy may be needed ifmay be needed if
tuberculosis is suspected andtuberculosis is suspected and
pericardiocentesis not diagnostic.pericardiocentesis not diagnostic.
 Other tests include looking for underlyingOther tests include looking for underlying
causes, e.g. blood cultures, autoantibodycauses, e.g. blood cultures, autoantibody
screen.screen.

21. TreatmentTreatment
 An underlying cause should be sought andAn underlying cause should be sought and
treated if possible.treated if possible.
 Most pericardial effusions resolveMost pericardial effusions resolve
spontaneously.spontaneously.
 However, when the effusion collects rapidlyHowever, when the effusion collects rapidly
and tamponade results, Pericardiocentesis isand tamponade results, Pericardiocentesis is
indicated.indicated.

22. Constrictive pericarditisConstrictive pericarditis
If the pericardium becomes so inelastic as toIf the pericardium becomes so inelastic as to
interfere with diastolic filling of the heart,interfere with diastolic filling of the heart,
constrictive pericarditis is said to haveconstrictive pericarditis is said to have
developed.developed.
CausesCauses::
 TuberculosisTuberculosis
 HaemopericardiumHaemopericardium
 Bacterial infectionBacterial infection
 May develop late after open-heart surgery.May develop late after open-heart surgery.

23.  Constrictive pericarditis should beConstrictive pericarditis should be
distinguished from restrictive cardiomyopathy.distinguished from restrictive cardiomyopathy.
 The two conditions are very similar in theirThe two conditions are very similar in their
presentation, but the former is fully treatable,presentation, but the former is fully treatable,
whereas most cases of the latter are not.whereas most cases of the latter are not.

24. Clinical features of ConstrictiveClinical features of Constrictive
PericarditisPericarditis
Symptoms and Signs:Symptoms and Signs:
 Reduced ventricular filling results in - Kussmaul'sReduced ventricular filling results in - Kussmaul's
sign, Friedreich's sign, pulsus paradoxussign, Friedreich's sign, pulsus paradoxus
 Systemic venous congestion results in - ascites,Systemic venous congestion results in - ascites,
dependent oedema, hepatomegaly and raised JVPdependent oedema, hepatomegaly and raised JVP
 Pulmonary venous congestion results in dyspnoea,Pulmonary venous congestion results in dyspnoea,
cough, orthopnoea, PNDcough, orthopnoea, PND
 ‘‘Pericardial knock’ heard in early diastole at thePericardial knock’ heard in early diastole at the
lower left sternal borderlower left sternal border

25. Investigations:Investigations:
 Chest X-rayChest X-ray: shows a relatively small heart.: shows a relatively small heart.
Pericardial calcification is present in up toPericardial calcification is present in up to
50%.50%.
 ECGECG
 EchocardiographyEchocardiography
 CT and MRICT and MRI are used to assess pericardialare used to assess pericardial
thicknessthickness

27. TreatmentTreatment
In Non Tuberculous cases -In Non Tuberculous cases -
 Early pericardiectomy is suggested, beforeEarly pericardiectomy is suggested, before
severe constriction and myocardial atrophysevere constriction and myocardial atrophy
have developed.have developed.

28. In Tuberculous cases –In Tuberculous cases –
 With pericardial calcification - early pericardiectomyWith pericardial calcification - early pericardiectomy
with antituberculous drug cover.with antituberculous drug cover.
 If there is no calcification, a course of antituberculousIf there is no calcification, a course of antituberculous
therapy should be attempted first.therapy should be attempted first.
 If the patient's haemodynamic state remains static orIf the patient's haemodynamic state remains static or
deteriorates after 4-6 weeks of therapy,deteriorates after 4-6 weeks of therapy,
pericardiectomy is recommended.pericardiectomy is recommended.