Pericardial diseases

Pericarditis

  • Acute inflammation of pericardium (± myocardial involvement)

    • MC causes are idiopathic & viral (coxsackie)

    • MI ➔ fibrinous pericarditis

      • Post-MI fibrinous pericarditis (after 1-3d)

      • Dressler syndrome (weeks-months)

    • Acute/chronic kidney failure ➔ ↑ urea ➔ inflammation

    • Radiation, cancer, Autoimmune (RA, SLE, scleroderma)

Constrictive Pericarditis

  • Pericarditis lasting > 3mo (chronic) ➔ thickened pericardium

  • Fibroblasts ➔ ↑ fibrin ➔ stiff pericardium ➔ ↓ diastolic filling ➔ venous congestion & ↓ SV ➔ ↓CO

Effusion (excess serous fluid or blood in pericardial cavity)

  • Acute pericarditis ➔ serous pericardial effusion

  • Trauma/postop, myocardial rupture (from MI) ➔ hemopericardium

Cardiac Tamponade (life threat)

  • Rapid accumulation of fluid ➔ compression of heart ➔ leftward septal shift ➔ ↓ diastolic filling ➔ venous congestion & ↓ SV ➔ ↓CO

    • Pericardium can stretch if given enough time

    • Rate of accumulation (too fast to clear) is what ➔ tamponade

SSX

Acute Pericarditis

  • Pleuritic chest pain, worse when supine, improves with leaning forward

  • Pericardial friction rub - during systole and early diastole, best heard with expiration while leaning forward

  • Fever

Effusion

  • Muffled heart sounds

  • Hoarseness/dysphagia/hiccups (compressed nerves/esophagus)

Constrictive Pericarditis

  • Right HF sx (from congestion) - JVD, Kussmaul's sign, edema, hepatomegaly

  • Left HF sx (from ↓ CO) - Dyspnea, fatigue

  • Pericardial knock - Early in diastole (stiff RV can't handle passive filling) ➔ high pitch S2.5 (not quite an S3 but after S2)

  • Pulsus paradoxus (↓ in systolic BP > 10 mmHg)

  • Late-stage ➔ a-fib (from atrial enlargement), hepatic dysfunction

DX

Acute Pericarditis

  • Since they're complaining of chest pain... EKG

    • Diffuse ST elevation & PR segment depression (except aVR)

    • aVR has ST depression & PR segment elevation

      • aVR usally has inverted T-waves but PR and J point are isoelectric

  • Troponin can be ↑ (if ↑↑↑ then think MI)

  • ↑ ESR, ↑ CK, ↑ CRP (good to monitor for efficacy of tx)

  • Get BUN (uremia), cultures, ANA & RF (autoimmune)

Effusion

Constrictive Pericarditis

  • ECHO (TEE > TTE)

    • Pericardial thickening with sudden halt during ventricular filling (diastole)

  • CXR, CT/MRI show calcifications of pericardium

  • Invasive cath: Rapid diastolic filling ➔ dip and restrictive filling ➔ plateau (Sq. root sign)

TX

  • NSAIDs ± colchicine - Only give colchicine alone if post-MI (Dressler’s)

    • Can try medical treatment before surgery if early-stage constrictive pericarditis

  • Pericardiectomy for constrictive pericarditis

  • Diuretics HF sx