Pericardial Disease¶
Chapter 281 | Part 6: Disorders of the Cardiovascular System
KEY CLINICAL POINTS¶
- Acute pericarditis is characterized by chest pain, pericardial friction rub, and ST-segment elevation on ECG with reciprocal T-wave inversions.
- Cardiac tamponade presents with Beck's triad (hypotension, jugular venous distension, muffled heart sounds) and may require pericardiocentesis.
- Chronic constrictive pericarditis shows restrictive hemodynamics with fixed diastolic filling defects and M-shaped atrial pressure waves.
- Differential diagnosis includes myocardial infarction, constrictive pericarditis, and pulmonary embolism.
- Management of recurrent pericarditis includes NSAIDs, colchicine, and corticosteroids for refractory cases.
1. DEFINITION & OVERVIEW¶
Pericardial disease encompasses conditions affecting the pericardium, including acute and chronic pericarditis, cardiac tamponade, and constrictive pericarditis. Acute pericarditis is the most common inflammatory process, while chronic constrictive pericarditis results from fibrosis and scarring of the pericardium.
Table 281-1 Classification of Pericarditis¶
| Clinical Classification | Etiologic Classification |
|---|---|
| I. Acute pericarditis (<6 weeks) | I. Infectious pericarditis |
| A. Fibrinous | A. Viral (coxsackievirus, herpesviruses, mumps, etc.) |
| B. Effusive (serous or sanguineous) | B. Pyogenic (pneumococcus, Staphylococcus, etc.) |
| II. Subacute pericarditis (6 weeks to 6 months) | C. Tuberculous |
| A. Effusive-constrictive | D. Fungal (histoplasmosis, coccidioidomycosis, etc.) |
| B. Constrictive | E. Other infections (syphilitic, protozoal, parasitic) |
| III. Chronic pericarditis (>6 months) | II. Noninfectious pericarditis |
| A. Constrictive | A. Acute idiopathic |
| B. Adhesive (nonconstrictive) | B. Renal failure |
| C. Neoplasia (primary or metastatic tumors) | |
| D. Trauma (penetrating/nonpenetrating chest wall) | |
| E. Aortic dissection, postirradiation, etc. |
1.1 Normal Functions of the Pericardium¶
The pericardium is a double-layered sac that restrains cardiac dilation, prevents infection spread, and maintains cardiac position. It contains 15–50 mL of serous fluid as an ultrafiltrate of plasma.
1.2 Acute vs. Chronic Pericardial Disease¶
Acute pericarditis (<6 weeks) is often viral or autoimmune, while chronic constrictive pericarditis (>6 months) results from fibrosis. Subacute pericarditis (6 weeks–6 months) may transition to constrictive or adhesive forms.
2. EPIDEMIOLOGY¶
Acute pericarditis is common, with viral etiologies accounting for 80–90% of cases. Constrictive pericarditis is rare, with tuberculosis (historically 50–70% of cases) and neoplasms as major causes. Cardiac tamponade occurs in 1–2% of hospitalized patients.
2.1 Risk Factors¶
Viral infections, autoimmune disorders (e.g., SLE, rheumatoid arthritis), post-cardiac injury (e.g., postpericardiotomy syndrome), and malignancies (e.g., lung, breast cancer) increase risk. Uremic pericarditis occurs in 1/3 of severe renal failure patients.
3. ETIOLOGY & PATHOPHYSIOLOGY¶
Acute pericarditis is primarily viral (e.g., coxsackievirus, mumps), autoimmune (e.g., SLE, rheumatoid arthritis), or post-infectious (e.g., post-MI Dressler's syndrome). Chronic constrictive pericarditis results from fibrosis of the pericardium, often from prior inflammation, tuberculosis, or radiation.
3.1 Viral Mechanisms¶
Viral infections cause inflammatory cytokine release, leading to pericardial inflammation. Coxsackievirus and adenovirus are common culprits, with viral RNA detected in pericardial fluid.
3.2 Autoimmune Pathogenesis¶
Autoimmune conditions (e.g., SLE, rheumatoid arthritis) trigger immune-mediated pericardial inflammation. Drug-induced lupus (hydralazine, procainamide) is a known cause.
4. CLINICAL FEATURES¶
Acute pericarditis presents with retrosternal chest pain, pericardial friction rub, and ECG changes (ST elevation, PR depression). Cardiac tamponade manifests as Beck's triad (hypotension, JVD, muffled heart sounds). Constrictive pericarditis shows restrictive hemodynamics with fixed diastolic filling defects.
4.1 Acute Pericarditis Symptoms¶
Chest pain (pleuritic, radiating to neck/shoulders), fever, malaise, and pericardial friction rub. Pain may mimic myocardial infarction but is relieved by sitting forward.
4,2 Cardiac Tamponade Signs¶
Beck's triad (hypotension, JVD, muffled heart sounds), paradoxical pulse, and electrical alternans. Physical exam may show Ewart's sign (pleural effusion with pericardial fluid).
5. DIFFERENTIAL DIAGNOSIS¶
Differentiate from myocardial infarction (chest pain precedes fever), constrictive pericarditis (fixed diastolic filling defects), and pulmonary embolism (pleuritic chest pain with hypoxia).
5.1 Mimicking Conditions¶
Myocardial infarction (pain precedes fever), constrictive pericarditis (M-shaped atrial waves), and pulmonary embolism (pleuritic pain with hypoxia).
6. INVESTIGATIONS & DIAGNOSIS¶
Echocardiography is the primary diagnostic tool for pericardial effusion and tamponade. ECG shows ST elevation and PR depression in acute pericarditis. Pericardial fluid analysis confirms tuberculous or neoplastic etiologies.
Table 281-2 Features Distinguishing Cardiac Tamponade from Constrictive Pericarditis¶
| Characteristic | Tamponade | Constrictive Pericarditis |
|---|---|---|
| Pulsus paradoxus | +++ | + |
| Prominent y descent | - | + |
| Prominent x descent | +++ | + |
| Kussmaul’s sign | - | + |
| Third heart sound | - | - |
| Pericardial knock | - | + |
| Low ECG voltage | ++ | + |
| Electrical alternans | ++ | - |
| Thickened pericardium | - | ++ |
| Pericardial effusion | +++ | - |
| RV size | Usually small | Usually normal |
| Respiratory variation in flow velocity | +++ | +++ |
| Equalization of diastolic pressures | - | +++ |
6.1 Diagnostic Algorithms¶
- Echocardiography for effusion/tamponade. 2. ECG for ST changes. 3. Pericardial fluid analysis (cytology, PCR for TB, ADA levels). 4. CT/MRI for loculated effusions or thickening.
7. MANAGEMENT & TREATMENT¶
Acute pericarditis is treated with NSAIDs (ibuprofen, aspirin), colchicine, and corticosteroids for refractory cases. Cardiac tamponade requires pericardiocentesis. Constrictive pericarditis may need pericardiectomy or windowing.
7.1 Acute Pericarditis¶
NSAIDs (ibuprofen 600–800 mg tid) + colchicine (0.5–0.6 mg qd). Corticosteroids (prednisone 1 mg/kg/day) for refractory cases (2–4 days). Avoid anticoagulants due to tamponade risk.
7.2 Cardiac Tamponade¶
Immediate pericardiocentesis under echocardiographic guidance. Intravenous fluids and vasopressors for hypotension. Surgical drainage for loculated effusions.
8. PROGNOSIS & COMPLICATIONS¶
Acute pericarditis has an excellent prognosis (95% recovery). Recurrent episodes occur in 25% of cases. Constrictive pericarditis may lead to heart failure, hepatic congestion, and ascites. Tamponade is life-threatening without prompt intervention.
8.1 Complications¶
Recurrent pericarditis, constrictive pericarditis, cardiac tamponade, and pericardial effusion with systemic complications (e.g., uremic pericarditis).
9. SPECIAL CONSIDERATIONS¶
Pregnancy is contraindicated in Eisenmenger syndrome due to maternal mortality risk. In elderly patients, constrictive pericarditis may mimic heart failure. Renal failure patients require dialysis optimization for uremic pericarditis.
9.1 Pregnancy¶
Contraindicated in Eisenmenger syndrome due to high maternal mortality. Contraception advised for women of childbearing age to avoid estrogen exposure.
10. KEY POINTS & CLINICAL PEARLS¶
- Acute pericarditis: ST elevation, PR depression, pericardial friction rub.
- Cardiac tamponade: Beck's triad, electrical alternans.
- Constrictive pericarditis: M-shaped atrial waves, fixed diastolic filling.
- Colchicine reduces recurrence risk in idiopathic pericarditis.
- Pericardiocentesis is lifesaving for tamponade.