This document discusses pericardial diseases, focusing on pericarditis, pericardial effusion, and cardiac tamponade. It defines the pericardium and its functions. It describes the symptoms, signs, and diagnostic criteria for acute pericarditis. Causes of pericarditis include infections, autoimmune disorders, neoplasms, radiation, renal failure, and trauma. Treatment involves NSAIDs, colchicine, or steroids depending on severity and recurrence risk. Pericardial effusion and tamponade can develop as complications, requiring drainage procedures or surgery.

1. PERICARDIAL DISEASES
DR VAROON R2 MEDICINE F UNIT

2. PERICARDIUM: ANATOMY
Fibro-serous sac

3. FUNCTION OF THE PERICARDIUM
1. Stabilization of the heart within the thoracic cavity -
ligamentous attachments -- limiting the heart’s motion.
2. Protection of the heart from mechanical trauma and
infection from adjoining structures.
3. The pericardial fluid functions as a lubricant and
decreases friction of cardiac surface during systole
and diastole.
4. Prevention of excessive dilation of heart especially
during sudden rise in intra-cardiac volume

4. PERICARDIAL DISEASES
PERICARDITIS
PERICARDIAL EFFUSION
AND CARDIAC
TAMPONADE
OTHERS : PERICARDIAL
CYSTS, TUMORS

5. PERICARDITIS
DEFINITION
CLASSIFICATION
BASED ON
1. DURATION
2. ETIOLOGY

6. DURATION
1. ACUTE PERICARDITIS - < 6 WEEKS
 FIBRINOUS
 EFFUSIVE (SEROUS OR SANGUINEOUS)
2. SUBACUTE – 6 WEEKS TO 6 MONTHS
 EFFUSIVE – CONSTRICTIVE
 CONSTRICTIVE
3. CHRONIC - > 6 MONTHS
 CONSTRICTIVE
 EFFUSIVE
 ADHESIVE ( NON CONSTRCTIVE)

7. ETIOLOGIES OF PERICARDITIS
I. INFECTIVE
1. VIRAL - Coxsackie A and B, Influenza, adenovirus,
HIV
2. BACTERIAL - Staphylococcus, pneumococcus,
TB, etc.
3. FUNGAL - Candida
4. PARASITIC - Amoeba, candida, etc.
II. AUTOIMMUNE DISORDERS
1. Systemic lupus erythematosus (SLE)
2. Drug-Induced lupus (e.g. Hydralazine,
Procainamide)
3. Rheumatoid Arthritis
4. Post Cardiac Injury Syndromes

8. III. NEOPLASM
1. Primary mesothelioma
2. Secondary, metastatic
3. Direct extension from adjoining tumor
(lung, bronchus, breast etc)
IV. RADIATION PERICARDITIS
V. RENAL FAILURE (uremia)
VI. TRAUMATIC CARDIAC INJURY
1. Penetrating - stab wound, bullet
wound
2. Blunt non-penetrating - automobile
steering wheel accident
VII. IDIOPATHIC

9. ACUTE PERICARDITIS
Four simple criteria for diagnosis
1. Chest pain
2. Pericardial rub
3. ECG findings
4. Pericardial effusion

10. CHEST PAIN
 Site : substernal, retrosternal or left precodial
 Radiating to trapezius ridge
 Relieved : sitting and leaning
 Aggravated : supine and inspiration
 Associated symptoms: dyspnea, cough,
hiccoughs
Differentiation from MI and Pleuritis

11. PERICARDIAL RUB
 Audible in 85%
 Site : left lower sternal border – leaning –
end of expiration
 Character : high pitch ( rasping, scratching,
grating, walking on crunchy snow or dry
leaves)
 3 Components corresponding to ventricular
systole , early diastolic filling and atrial
contraction

12. ELECTROCARDIOGRAM : ECG
 Stage 1 : widespread ST elevation often with
concavity upward : 2-3 limb leads: V2-V6
Reciprocal depression in aVR, V1
 Stage 2 : after several days , ST = Normal
 Stage 3 : T inversion
 Stage 4 : After weeks or months, ECG =
Normal

14. APPROACH
 It’s a clinical diagnosis based on history and
examination
 ECG
 BLOOD TESTS : Hemogram , Biochemistry
Cardiac enzymes
Serum ANA – ENA - RF
TSH , CRP , ESR
Others based on suspected etiology
 CXR , 2DECHO

15. TREATMENT
 Acute idiopathic pericarditis
Self limiting in 70% to 90%
 Symptomatic
 NSAIDS : Ibuprofen (600mg – 800mg TDS)
Aspirin (2-4mg/d)
 NARCOTIC: Morphine
 COLCHICINE ( 2-3mg loading with 1mg 10-14d)
 STERIODS : avoid : recurrences
 60mg x 2d and then taper in week.

16. RELAPSING AND RECURRENT PERICARDITIS
 15% - 30%
 Initial relapse : 2 weeks NSAIDS/colchicine
 Recurrent pericardial pain :
Steriods : longer duration : low dose – 0.2 –
0.5 mg mg/kg
 Hyperimmune Globulin : CMV(4ml/kg on
0,4,8d f/b 2ml/kg on 12, 16) , Adeno, Parvo
 Interferon alpha 2.5 M IU/M2 3/week :
Coxsackie B

17. COMPLICATIONS
PERICARDIAL EFFUSION
CARDIAC TAMPONADE
CONSTRICTION

18. PERICARDIAL EFFUSION
Normal 15-50 ml of fluid
ETIOLOGY
1. Inflammation : infection, immunologic process.
2. Trauma : bleeding in pericardial space.
3. Noninfectious :
a. increase in pulmonary hydrostatic pressure e.g.
congestive heart failure.
b. increase in capillary permeability e.g.
hypothyroidism
c. decrease in plasma oncotic pressure e.g.
cirrhosis.
4. Decreased drainage : obstruction of thoracic
duct : malignancy or damage during surgery.

19. PATHOPHYSIOLOGY
Stiff pericardium
Symptoms of
cardiac
compression
depends on:
1. Volume of fluid
2. Rate of fluid
accumulation
3. Compliance
characteristics of

20. CLINICAL FEATURES
Small effusions do not produce hemodynamic
abnormalities.
Large effusions
Hemodynamic Instability
Compression of adjoining structures
dysphagia (compression of esophagus)
hoarseness (recurrent laryngeal nerve
compression)
hiccups (diaphragmatic stimulation)
dyspnea (pleural inflammation/effusion)
Chest pain, pressure, discomfort
Light-headedness, syncope
Palpitations

21. CARDIAC TAMPONADE
 Definition : fluid sufficient to cause
obstruction to inflow of blood in ventricles
 Minimum 200ml
 Directly proportional to thickness of
ventricular myocardium
 Inversely thickness of parietal pericardium
 Three common causes : neoplastic ,
idiopathic, pericardial effusion secondary to
renal failure

22. CARDIAC TAMPONADE -- PATHOPHYSIOLOGY
Accumulation of fluid under high pressure:
compresses cardiac chambers & impairs
diastolic filling of both ventricles
 SV venous pressures
 CO systemic pulmonary congestion
Hypotension/shock JVD rales
Reflex tachycardia hepatomegaly
ascites
peripheral edema

23. TAMPONADE
Acute: (trauma, LV rupture)
Profound hypotension
Confusion/Agitation
Slow/Progressive large effusion (weeks)
Fatigue (CO)
Dyspnea
Orthopnea
Hepatic engorgement

24. EXAMINATION AND FINDINGS
BECK’S TRIAD
 HYPOTENSION
 SOFT OR ABSENT HEART SOUNDS
 JUGULAR VENOUS DISTENSION WITH
PROMINENT X DESCENT BUT AN ABSENT
Y DESCENT

25. PULSUS PARADOXUS
Inspiration: negative intrathoracic pressure is
transmitted to the pericardial space
 IPP
 blood return to the right ventricle
 jugular venous and right atrial pressures
 right ventricular volume  interventricular
septum shifts towards the left ventricle
 left ventricular volume
 LV stroke volume
  blood pressure (<10mmHg is normal) during
inspiration

26. GENERAL EXAMINATION
TACHYCARDIA
HEPATOJUGULAR REFLUX
TACHYPNEA
WEAKENED PERIPHERAL
PULSES, EDEMA, AND CYANOSIS
RAISED JVP

27. SYSTEMIC EXAMINATION
 MUFFLED HEART SOUNDS
 PERICARDIAL RUB
 TUBULAR BREATH SOUNDS : LEFT
AXILLA OR LEF BASE : BRONCHIAL
COMPRESSION
 EWART SIGN: DULLNESS TO
PERCUSSION BENEATH THE ANGLE OF
LEFT SCAPULA and INCREASED
FREMITUS
 HEPATOSPLENOMEGALY

28. DIAGNOSTIC STUDIES
CHEST XRAY : WATER BOTTLE

29. ECG : ELECTROCARDIOGRAM
LOW VOLTAGE
ELECTRICAL ALTERNANS

30. 2DECHO

31. RIGHT HEART CATHETERIZATION
Catheterization Findings:
Elevated RA and RV diastolic pressures
Equalized diastolic pressures
Blunted “y” descent in RA tracing
y descent: early diastolic filling (atrial emptying)
 BP and Pulsus paradoxus
Pericardial pressure = RA pressure

32. TREATMENT
Surgical procedures
 Pericardiectomy
 Pericardiocentesis
 Pericardial window placement
 Pericardiotomy.

33. PERICARDIOCENTESIS
 Pericardiocentesis is the aspiration of fluid
from the pericardial space that surrounds the
heart.

34. CONTRAINDICATIONS
Absolute contraindications
 In the hemodynamically unstable patient, no
absolute contraindications
Relative contraindications
 Uncorrected bleeding disorder
 Traumatic cardiac tamponade. Some authors
argue that traumatic cardiac tamponade
should be treated by emergent thoracotomy.

35. POSITION
 Position the patient in a semirecumbent
position at a 30- to 45-degree angle. This
position brings the heart closer to the anterior
chest wall.
 The supine position is an acceptable
alternative.

36. APPROACH
Anatomic
landmarks :
xiphoid process,
5th and 6th ribs
The subxiphoid
and the left
sternocostal
margin are the
most commonly
used sites (black

38. Complications
 Dysrhythmias
 Coronary artery puncture or aneurysm
 Left internal mammary artery puncture or
aneurysm
 Hemothorax
 Pneumothorax
 Pneumopericardium
 Hepatic injury
 False-negative aspiration – Clotted blood in the
pericardium
 False-positive aspiration – Intracardiac aspiration

39. PERICARDIECTOMY
 Pericardiectomy is the most effective
surgical procedure for managing large
effusions, because it has the lowest
associated risk of recurrent effusions.
This procedure is used for constrictive
pericarditis, effusive pericarditis, or
recurrent pericarditis with multiple
attacks, steroid dependence, and/or
intolerance to other medical
management.

40. PERICARDIAL WINDOW
 Pericardial window placement is used for
effusive pericarditis therapy. In critically ill
patients, a balloon catheter may be used to
create a pericardial window, in which only 9
cm2 or less of pericardium is resected.

41. PERICARDIOTOMY
 Consider subxiphoid pericardiotomy for large
effusions that do not resolve. This procedure
may be performed under local anesthesia
and has a lower risk of complications than
pericardiectomy.

42. TREATMENT FOR SPECIFIC
CAUSES OF PERICARDITIS

43.  Infectious pericarditis
 Bacterial pericarditis : appropriate
antibiotics for at least 4 weeks and
drainage of pericardial fluid.
 Fungal infection : fluconazole,
ketoconazole, itraconazole, amphotericin
B, liposomal amphotericin B, or
amphotericin B lipid complex
Corticosteroids and NSAIDs can be used
to support the antifungal drug treatment.

44.  Intrapericardial fibrinolysis : thick, loculated
fluid, but open surgical drainage is preferred.
Occasionally, patients require partial to total
pericardiectomy.
 Tubercular infection : AKT
 Use of adjunctive prednisolone in patients
with acquired immunodeficiency syndrome
(AIDS) may reduce mortality in this
population.

45. METABOLIC PERICARDITIS
 RENAL FAILURE associated uremic
pericarditis : HEMODIALYSIS
 Hemodialysis : hypotension, which may
be dangerous in the setting of
tamponade.
In addition, some physicians advocate
heparin-free hemodialysis to reduce the
risk of intrapericardial hemorrhage.

46.  Peritoneal dialysis may compromise
respiratory function because of the effect of
intraperitoneal fluid on the diaphragm.
 In dialysis-associated pericarditis, an
increased intensity of dialysis for 10-14 days
is recommended.
Correct hypophosphatemia and hypokalemia

47.  Cardiovascular pericarditis
 Pericarditis does not contraindicate
thrombolytic or anticoagulant therapy for an
acute MI.
 However, anticoagulation should be
discontinued if pericardial effusion develops
or effusion size increases. Treatment is with
aspirin.
 In Dressler syndrome, anticoagulant therapy
should be stopped because of the risk of
hemorrhagic pericarditis. Treatment is with
NSAIDs.

48. CONSTRICTIVE PERICARDITIS
Late complication of pericardial disease
Fibrous scar formation
Fusion of pericardial layers
Calcification further stiffens pericardium
Etiologies:
any cause of pericarditis
idiopathic
post-surgery
mc : tuberculosis
radiation
neoplasm

49. PATHOPHYSIOLOGY
Rigid, scarred pericardium encircles heart:
Systolic contraction normal
Inhibits diastolic filling of both ventricles
 SV venous pressures
 CO systemic pulmonary congestion
Hypotension/shock JVD rales
Reflex tachycardia hepatomegaly
ascites
peripheral edema

50. PHYSICAL EXAMINATION
Findings of right heart failure :
• HR, BP
• Ascites, edema, hepatomegaly
• BROADBENT SIGN : apical impulse is
reduced and retract in systole
• early diastolic “knock” after S2 sudden
cessation of ventricular diastolic filling
imposed by rigid pericardial sac
• Kussmaul’s sign
• Square root sign

51. DIAGNOSIS
CXR: calcified cardiac silhouette
ECG: non-specific, AF
CT or MRI: pericardial thickening

52. 2D ECHO
 Pericardial thickening
 Dilatation of IVC and hepatic veins
 Sharp halt in ventricular filling in early
diastole
 Flattening of left ventricular posterior wall
 Atrial enlargement

53. TREATMENT
PERICARDIAL
RESECTION

54. CLINICAL TAMPONADE CONS. PERIC. RESTR. CM RVMI
PULSUS
PARADOXUS
COMMON ----- RARE RARE
JVP Y
DESCENT
---- P RARE RARE
JVP X
DESCENT
P P P RARE
KAUSSMAUL ----- P ------ P
THIRD HS ------ ----- RARE P
PERICARDIAL
KNOCK
------ P ------- ------

55. 2DECHO TAMPONA
DE
CONS.
PERIC.
RESTR.
CM
RVMI
THICKENED PERCARDIUM ------ P ------ -----
PERICARDIAL CALCIFICATION ---- P ------ ------
PERICARDIAL EFFUSION P ----- ----- -----
RV SIZE SMALL N N ENLARG
E
MYOCARDIAL THICKNESS N N INCRE N
RHT ATRIAL COLLAPSE AND
RVDC
P ------ ------- ------
INCREASED EARLY FILLING,
INCREASED MITRAL FLOW
VELOCITY
---- P P P
EXAGGERATED RESP
VARIATION IN FLOW VELOCITY
P P ---- -----

56. TAMPONADE CONS. PERIC. RESTR. CM RVMI
ECG LOW
VOLTAGE
P P P --
ECG
ELECTRICAL
ALTERNANS
P --- -- --
CT MRI
THICKEN /
CALCIFIC
PERICARDIU
M
--- P ---- -----
CARDIAC
CATHERIZATI
ON
EQUALIZATIO
N OF
DIASTOLIC
PRESSURES
----- P ------ -----

57.  Pericardial cysts : MC : rht cardioprehnic
angle
 Tumors : primary and secondary ( lung,
bronchus, breast, mediastinal, lymphoma,
melanoma)
MC primary malignant : mesothelioma