Pericardial Diseases

Dr(Lt Col) Ashutosh OjhaReader Internal MedicinePericardial Diseases

Pericardium -IntroPericardium is a double-layered sac; Visceral pericardium is a serous membrane that is separated by a small quantity (1550 mL) of fluid, Pericardial Fluid- ultrafiltrate of plasma, secreted from the parietal pericardium.

Pericardium -FunctionPrevents sudden dilation of the cardiac chambersRestricts the anatomic position of the heart Minimizes friction between the heart and surrounding structures Prevents displacement of the heart and kinking of the great vessels, and Probably retards the spread of infections from the lungs and pleural cavities to the heart. Nevertheless, total absence of the pericardium, either congenital or after surgery, does not produce obvious clinical disease.

DiseasesAcute PericarditisCardiac TamponadeChronic PericarditisPericardial Neoplasm

Classification of Pericarditis

Etiologic ClassificationHarrisons Principles of Internal Medicine-19 th Edn

Etiologic ClassificationHarrisons Principles of Internal Medicine-19 th EdnPericarditis presumably related to hypersensitivity or autoimmunityA. Rheumatic fever B. Collagen vascular disease (systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, scleroderma, acute rheumatic fever, granulomatosis with polyangiitis (Wegener's) C. Drug-induced (e.g., procainamide, hydralazine, phenytoin, isoniazide, minoxidil, anticoagulants, methysergide) D. Post-cardiac injury 1. Postmyocardial infarction (Dressler's syndrome) 2. Postpericardiotomy 3. Posttraumatic

Acute pericarditis Clinical featuresmost common pathologic process involving the pericardiumChest pain pericardial friction rub electrocardiogram (ECG)

Acute pericarditis ECG featuresStage 1 Widespread elevation of the ST segments, with upward concavity, involving two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and sometimes V1, Depression of the PR segment below the TP segment reflecting atrial involvement. No significant changes in QRS complexes. In Stage 2, after several days, the ST segments return to normal, Stage 3- Do the T waves become inverted ECG returns to normal in Stage 4

ECG

CXR-PA View

Other Bedside InvEchocardiography is the most widely used imaging technique since it is sensitive, specific, simple, and noninvasive; may be performed at the bedside; and can identify accompanying cardiac tamponade .

Cardiac TamponadeThe accumulation of fluid in the pericardial space in a quantity sufficient to cause serious obstruction to the inflow of blood to the ventricles .

Cardiac Tamponade-Cl featuresHypotension, Soft or absent heart sounds, Jugular venous distention with a prominent x descent but an absent y descent. Pulsus paradoxus

The quantity of fluid necessary to produce this critical state may be as small as 200 mL when the fluid develops rapidly or >2000 mL in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume

Difficult to diagnoseA high index of suspicion for cardiac tamponade is required since in many instances no obvious cause for pericardial disease is apparent, and it should be considered in any patient with otherwise unexplained enlargement of the cardiac silhouette, hypotension, and elevation of jugular venous pressure. There may be reduction in amplitude of the QRS complexes, and electrical alternans of the P, QRS, or T waves should raise the suspicion of cardiac tamponade.

CausesNeoplasmIdeopathic Renal

Immediate RxPericardiocentasis

Further work upPericardial fluid analysisADAMalignant Cells

Viral or Idiopathic Form of Acute Pericarditis

CMV ,EBVShort benign course