Internal Medicine: Cardiology: Pericardial Disease
Introduction
The etiologies of all pericardial diseases are the same. We could ETIOLOGY CATEGORIES
memorize 50+ causes of pericardial disease, but it’s better to simply
Viral (coxsackie)
learn categories and keep a reference nearby to obtain the specifics. Bacterial (strep/staph)
Infections, autoimmune diseases, trauma, and proximate cancers Infections
TB
(lung, breast, esophagus, and mediastinum) cause pericardial disease. Fungus
If acute, they cause an inflammatory condition (pericarditis). If they Lupus, Rheumatoid, Scleroderma
happen to make fluid they cause an effusion, or in its worst form, Autoimmune
Procainamide, Hydralazine, Uremia
tamponade. If chronic, the inflammatory condition can be around
Trauma Blunt, Penetrating
long enough to cause fibrosis, which leads to constrictive pericarditis.
Focus on identification and treatment rather than etiology. Cancers Lung, Breast, Esophagus, Lymphoma
Others Many…
Pericarditis
Pericarditis is an inflammatory disease with an inflammatory DISEASE TREATMENT
treatment. It presents as pleuritic and positional (better when Pericarditis NSAIDs + Colchicine
leaning forward) chest pain that will have a multiphasic friction
Pericardial effusion Pericarditis
rub. Caused by an inflammation of the sac around the heart, every
heartbeat causes irritation, producing constant pain. An ECG will Recurrent Effusion Pericardial Window
show diffuse ST segment elevation (caution MI), but what is Tamponade Pericardiocentesis
pathognomonic is PR segment depression. An echo will show an Constrictive Pericarditis Pericardiectomy
effusion but not the inflammation . . . Echo is the wrong answer.
Theoretically, MRI is the best radiographic test, but is often not
needed. The treatment is NSAIDs + colchicine. There may be ST elevation
times where either NSAIDs or colchicine can’t be used; in that
case monotherapy is used. Steroids are used in refractory cases, but
associated with recurrence; they’re usually the wrong answer. PR depression
Pericardial Effusion/Tamponade Heart Pericardial
When fluid accumulates in the pericardial space, there’s pericardial Space Pericardium
effusion. If that effusion is slowly developing or small in size, it may
just be an incidental finding on echo. If it progresses quickly or gets
large, there may be symptoms. These symptoms will be those of CHF: Pericardium
dyspnea on exertion, orthopnea, and PND. Diagnose the effusion
with an echocardiogram. Pericardial effusions are secondary to an Effusion Tamponade
underlying cause. Treat the effusion by treating the cause. Most
often an effusion develops in the setting of pericarditis; treating
the pericarditis treats it. But if the effusion is large, refractory, or
recurrent, a pericardial window (literally a hole in the pericardium) Loose fluid produces Tight fluid crushes
can be made so that the fluid drains into the chest rather than into rub, Ø compromise ventricle, compromise
the pericardial space.
If the effusion is rapid (or there’s ventricular hemorrhage), the
pericardium fills without time to compensate. This produces Pericardial window
tamponade. Beck’s triad (JVD, hypotension, distant heart allows fluid to drain
sounds), clear lungs, and pulsus paradoxus > 10 mmHg make the
clinical diagnosis. Do EMERGENT pericardiocentesis. An echo DIASTOLE SYSTOLE
facilitates the diagnosis but is neither necessary nor sufficient.
Constrictive Pericarditis Normal
If an inflammatory process is left untreated long enough, fibrosis
will set in. The loose membrane of the pericardium becomes fixed
and rigid. It causes no trouble with contractility, but the heart relaxes Constrictive
into a rigid box, limiting filling. As the heart expands into too-small- Pericarditis
a-space, it strikes the walls of the box and causes a pericardial knock.
Diagnosis is made with an echocardiogram. Treat by removing the
rigid pericardium with a pericardiectomy.
© OnlineMedEd. http://www.onlinemeded.org 1
