Disease of Pericardium: DR Peter R Kisenge

Disease of pericardium
DR peter R Kisenge
Introduction
The pericardium is a fibroelastic sac
made up of visceral and parietal
layers separated by a (potential)
space, the pericardial cavity.
In healthy individuals, the pericardial
cavity contains 15 to 50 mL of an
ultrafiltrate of plasma.
Acute pericarditis
Aetiology
Common- Acute MI, Viral (eg) Viral
Coxasackie, Tuberculosis, Rheumatic
fever
Less common- uraemia, malignant
disease, trauma, connective tissue
disease
DIAGNOSTIC CRITERIA AND

CLINICAL PRESENTATION
The major clinical manifestations of
acute pericarditis include
Chest pain
Pericardial friction rub
ECG changes new widespread ST
elevation or PR depressions.
Pericardial effusion
The presence of pericarditis should also

be suspected in the following clinical
settings:
Persistent high fever in patients with
pericardial effusion
Unexplained new radiographic
cardiomegaly Unexplained hemodynamic
deterioration after myocardial infarction
cardiac surgery, or a cardiac diagnostic
or interventional procedures
Chest painThe chest pain of acute

pericarditis is typically fairly sudden in
onset and occurs over the anterior chest.
It is often pleuritic in nature, being sharp
and exacerbated by inspiration.
However, dull, oppressive pain, which is
difficult to distinguish from that of
myocardial ischemia, can occur.
The pain may decrease in intensity when
the patient sits up and leans forward and
may radiate, especially to one or both
trapezius ridges
Pericardial friction rubA

pericardial friction rub is highly
specific for acute pericarditis.
The sensitivity is variable, varying in
part with the frequency of
auscultation since rubs tend to vary
in intensity and can come and go
over a period of hours
TESTINGThe electrocardiogram
(ECG) is the often the most helpful
test in the evaluation of the patients
with suspected acute pericarditis
Echocardiography is often normal, but
is an essential part of the evaluation,
due to the possibility of an associated
pericardial effusion and tamponade.
ECG evolutionThe
electrocardiogram in acute
pericarditis evolves through four
stages
Stage 1, seen in the first hours to
days, is characterized by diffuse ST
elevation (typically concave up) with
reciprocal ST depression in leads aVR
and V1
Stage 2 is characterized by normalization

of the ST and PR segments
Stage 3 is characterized by the
development of diffuse T wave inversions,
generally after the ST segments have
become isoelectric.
In stage 4, the ECG may become normal
or the T wave inversions may persist
indefinitely ("chronic" pericarditis)
Management
The pain usually relieved by asprin
(600mg 4hourly) but a more potent
anti inflamatory agents such as
indometacin 25mg q8h
Cotecosteroid may suppress
symptom but there is no evidence
that they accelerate the cure.
Pericardial Effusion
Pericardial effusion can develop in
patients with acute pericarditis or
may be seen as an incidental and
silent finding in a variety of systemic
disorders
ETIOLOGYPericardial effusion can
occur as a component of almost any
pericardial disorder
Aetiology
Acute idiopathic or viral pericarditis

Purulent pericarditis
Tuberculous pericarditis
Postmyocardial infarction or cardiac surgery
Recent or remote sharp or blunt chest trauma,
including a cardiac diagnostic or interventional
procedure HIV infection
Malignancy, especially lung and breast cancer
Hodgkin's disease,
mesothelioma Mediastinal radiation
recent or remote Collagen vascular diseases
Dialysis and,
chronic renal failure Hypothyroidism, especially
myxedema
DIAGNOSTIC APPROACHThe presence

of pericardial effusion may be suspected
from the history
Electrocardiogram (ECG), and chest x-ray.
The presence of pericardial effusion
should be suspected in the following
clinical settings, particularly in patients
with any of the above disorders known to
involve the pericardium:
All cases of acute pericarditis.

Otherwise unexplained persistent fever with
or without an obvious source of infection
which raises the possibility of purulent
pericarditis.
Unexplained new radiographic cardiomegaly
without pulmonary congestion.
Unexplained hemodynamic deterioration
after myocardial infarction, cardiac surgery,
or an invasive cardiac diagnostic or
interventional procedure.
ECG Two ECG findings suggestive

of pericardial effusion are low QRS
voltage and electrical alternans.
Low voltage is probably due to shortcircuiting of cardiac potentials by the
fluid surrounding the heart.
Low voltage is usually defined as
QRS complexes 5 mm (0.5 mV) in all
of the limb leads.
Chronic Constrictive
pericarditis
Is due to progressive thickening
fibrosis and calcification of the
pericardium.
In effect, the heart is encased in a
solid shell and can not fill properly,
calcification may extend into
myocardium, so there may also be
impaired myocardial contraction
Clinical feutures
Fatique
Rapid, low volume pulse
Pulse paradoxus
ElevatedJVP
Loud early third heart sound or
pericardial knok
Ascites
Peripheral oedema
Management
Surgical resection

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Disease of pericardium

DIAGNOSTIC CRITERIA AND

The presence of pericarditis should also

Chest painThe chest pain of acute

Pericardial friction rubA

Stage 2 is characterized by normalization

Acute idiopathic or viral pericarditis

DIAGNOSTIC APPROACHThe presence

All cases of acute pericarditis.

ECG Two ECG findings suggestive

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