Pericardial disease Notes

NOTES NOTES PERICARDIAL DISEASE GENERALLY, WHAT IS IT? PATHOLOGY & CAUSES ▪ Disorders affecting pericardium ▪ Pericardial cavity: space between visceral, parietal layer, normally filled with 15–50ml of plasma filtrate CAUSES Infections: mostly viral; bacterial, fungal rare Malignancy, mediastinal radiation Dressler’s syndrome Trauma Drugs, toxins Metabolic disease (e.g. uremic syndrome, myxedema, ovarian hyperstimulation syndrome), connective tissue disease ▪ Immune-mediated disorders ▪ ▪ ▪ ▪ ▪ ▪ COMPLICATIONS ▪ Heart failure, circulatory problems, problems breathing SIGNS & SYMPTOMS ▪ See individual diseases DIAGNOSIS DIAGNOSTIC IMAGING ▪ Echocardiogram ▪ X-ray OTHER DIAGNOSTICS ▪ ECG TREATMENT ▪ Pericardiocentesis, pericardiectomy MNEMONIC: CARDIAC RIND Causes of Pericarditis Collagen vascular disease Aortic aneurysm Radiation Drugs Infections Acute renal failure Cardiac infarction Rheumatic fever Injury Neoplasms Dressler’s syndrome OSMOSIS.ORG 97

ACUTE PERICARDITIS osms.it/acute-pericarditis PATHOLOGY & CAUSES ▪ Pericardial inflammation, myopericarditis ▪ Most common pericardial disorder CAUSES ▪ Idiopathic, viral (e.g. Coxsackie B), uremic syndrome (toxic to pericardium), Dressler’s syndrome, autoimmune (e.g. rheumatoid arthritis, scleroderma, systemic lupus erythematosus), cancer, radiation, medications (e.g. penicillin, anticonvulsants) RISK FACTORS ▪ Surgery, cancer, autoimmune disease, connective tissue disorders, immunosuppression 98 OSMOSIS.ORG COMPLICATIONS ▪ Constrictive pericarditis, pericardial effusion, cardiac tamponade SIGNS & SYMPTOMS ▪ Fever, sharp chest pain worsened with deep breathing, symptoms improve with sitting up and leaning forward ▪ Pericardial friction rub heard on auscultation, like two pieces of leather rubbing together, loudest on left sternal border

Chapter 14 Pericardial Disease DIAGNOSIS TREATMENT DIAGNOSTIC IMAGING ▪ Targeted at etiology X-ray ▪ “Water bottle sign,” liquid collects at the bottom if effusion present MEDICATIONS Echocardiography ▪ Performed to exclude pericardial effusion OTHER INTERVENTIONS ▪ Clinical presentation suggestive of pericardial effusion ECG ▪ ST elevation, PR depression, voltage changes, flattened, inverted T wave MNEMONIC: PSPPS ▪ Treat pain, inflammation ▫ Non-steroidal anti-inflammatory drug (NSAID) + colchicine ▫ Glucocorticoids if NSAID contraindicated ▫ Colchicine important if rheumatoid arthritis, Dressler syndrome involved SURGERY ▪ Pericardiotomy if high recurrence OTHER INTERVENTIONS ▪ Rest Acute pericarditis ECG PericarditiS PR depression in Precordial leads ST elevation Figure 14.2 Illustration depicting sclerosing of pericardial tissues in cross-section of heart wall. Figure 14.1 A chest radiograph demonstrating the globular cardiac silhouette seen in a case of pericardial effusions secondary to acute pericarditis. This is also known as the water bottle sign. OSMOSIS.ORG 99

Figure 14.4 Histology photomicrograph demonstrating acute pericarditis. The mesothelial cells of the pericardium are surrounded by neutrophils and there is no fibrosis, indicating an acute inflammatory reponse. Figure 14.3 Gross pathology of acute fibrinous pericarditis. The yellow fibrinous exudate is clearly visible on the external surface of the heart. CARDIAC TAMPONADE osms.it/cardiac-tamponade PATHOLOGY & CAUSES ▪ Buildup of fluid in pericardium, constricts heart ▪ Tamponade = pressure obstructing flow ▪ Heart unable to pump normally → blood flow through chambers obstructed → cardiac output decreases → hypotension → lower tissue perfusion → heart rate increases CAUSES ▪ Acute onset: trauma, myocardial infarction, aortic dissection, pericardial effusion ▪ Slow onset: cancer, chronic inflammation, uremic pericarditis, hypothyroidism, connective tissue disease 100 OSMOSIS.ORG RISK FACTORS ▪ Individuals with malignancy, tuberculous, purulent pericarditis ≥ those with idiopathic pericarditis ▪ Individuals with fibrinolytic therapy, myocardial infarction SIGNS & SYMPTOMS ▪ Pulsus paradoxus due to ventricular interdependence ▪ Beck’s triad (see mnemonic) ▪ Tachycardia, coughing, dyspnea, weakness, myocardial ischemia

Chapter 14 Pericardial Disease MNEMONIC: 3Ds Beck’s triad (Signs & Symptoms) Distant heart sounds Distended jugular veins Decreased arterial pressure DIAGNOSIS DIAGNOSTIC IMAGING Echocardiography ▪ Excess pericardial fluid, heart “swinging” inside pericardial cavity Figure 14.5 A CT scan in the axial plane demonstrating a large pericardial effusion, separating the pericardium from the heart itself and increasing the intrapericardial pressure, leading to cardiac tamponade. SURGERY TREATMENT ▪ Cardiac catheterization → pressure in all four chambers equal OTHER INTERVENTIONS ▪ Clinical presentation ECG ▪ Tachycardia, low QRS complex voltage, electrical alternans (QRS complexes have different heights) MEDICATIONS ▪ IV fluids OTHER INTERVENTIONS Pericardiocentesis ▪ Needle inserted into pericardium to drain excess fluid Figure 14.6 Illustration depicting fluid build up around pericardium, putting pressure on the heart walls and decreasing stroke volume. OSMOSIS.ORG 101

CONSTRICTIVE PERICARDITIS osms.it/constrictive-pericarditis PATHOLOGY & CAUSES ▪ Formation of thick, fibrotic pericardium → compresses heart ▪ Fibroblasts accumulate between pericardial layers → collagen deposits → creates scars → layers become adherent, lose elasticity ▪ Heart filling difficult due to stiffness of pericardium ▫ Ventricular interdependence: lowered heart wall compliance, decreased transpulmonary venous pressure → left ventricular filling decreases → lower volume in left heart → right bends septum towards left to increase volume ▫ Maximal volume diminished, continues to decrease with disease progression ▪ Volume overload, hepatopathy, decreased cardiac output CAUSES ▪ Idiopathic, viral, radiation, myocardial infarction, collagen disorders, tuberculosis RISK FACTORS ▪ Acute pericarditis ▪ Cardiac surgery, radiation, connective tissue disorders, bacterial (purulent) infections COMPLICATIONS ▪ Heart failure, arrhythmias, cardiac tamponade ▪ Edema: part of fluid overload; ascites, hepatosplenomegaly (HSM), cachexia (signs of hepatopathy); dyspnea (consequence of low cardiac output) ▪ Clinical manifestations of pleural effusion DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Pericardial calcifications Echocardiogram ▪ Stiff serous pericardium restricts heart’s movement CT scan ▪ Anatomical variations, thickness, distribution of scarring LAB RESULTS Plasma brain natriuretic peptide (BNP) ▪ Differentiate between tamponade, cirrhosis, restrictive cardiomyopathy OTHER INTERVENTIONS Invasive hemodynamic monitoring ▪ Increased pressure in right atrium, Kussmaul’s sign SIGNS & SYMPTOMS ▪ Elevated jugular venous pressure (JVP) ▪ Kussmaul’s sign: paradoxical inspiratory JVP ▪ Pericardial knock: heard before S3 on auscultation 102 OSMOSIS.ORG TREATMENT MEDICATIONS ▪ Diuretics, NSAIDs, corticosteroids SURGERY ▪ Pericardiectomy (for progressive disease)

Chapter 14 Pericardial Disease Figure 14.7 A chest radiograph demonstrating pericardial calcification secondary to a chronic pericarditis. DRESSLER'S SYNDROME osms.it/dresslers-syndrome PATHOLOGY & CAUSES ▪ ▪ ▪ ▪ Secondary pericarditis, rare AKA postmyocardial infarction syndrome May or may not involve pericardial effusion ≥ two weeks after myocardial infarction (MI), immune-mediated response to injury → antimyocardial antibodies respond to cardiac antigens → immune complex deposits in pericardium, pleura SIGNS & SYMPTOMS ▪ Unusual fatigue after cardiac surgery/MI ▪ Persistent fever, tachycardia, pulsus paradoxus ▪ Manifestations of pericarditis: friction rub, symptoms improve in sitting position ▪ Pleural effusion signs: pleuritic pain DIAGNOSIS DIAGNOSTIC IMAGING Echocardiogram ▪ Evaluate ventricular contractility; effusion, signs of tamponade Chest X-ray ▪ Cardiac effusion LAB RESULTS ▪ Complete blood count (CBC), CRP, erythrocyte sedimentation rate (ESR); troponin studies show leukocytosis, ↑ CRP, ↑ ESR; anti-heart antibody titer OTHER INTERVENTIONS ECG ▪ Changes same as acute pericarditis ▪ ST segment elevation, PR depression OSMOSIS.ORG 103

TREATMENT MEDICATIONS ▪ Colchicine recommended after cardiac surgery as preventative measure ▪ High dose aspirin, NSAIDs, corticosteroids PERICARDIAL EFFUSION osms.it/pericardial-effusion PATHOLOGY & CAUSES ▪ Abnormal accumulation of inflammatory fluid, immune cells → diffuse into interstitium → fluid pools in pericardial space → pericardial dilation → pressure on heart, vena cava → decreased cardiac filling → cardiac tamponade → decreased cardiac output ▪ Types of effusion: serous, serosanguinous, chylous CAUSES ▪ Aortic dissection, heart failure, hypoalbuminemia, lymphatic obstruction, malignancy, radiation, renal failure, trauma, autoimmune disease, acute pericarditis (viral, bacterial, tuberculous, idiopathic in origin), myxedema, some drugs, iatrogenic, idiopathic COMPLICATIONS DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Silhouette pools to bottom of heart, gives classic “water bottle” sign Echocardiogram ▪ Pericardial effusion makes heart looks like it’s dancing within pericardium, “swinging heart” LAB RESULTS ▪ Elevated markers of inflammation: C-reactive protein (CRP) OTHER INTERVENTIONS ECG ▪ Low QRS complex voltage, electrical alternans, sinus tachycardia ▪ Cardiac tamponade ▪ Constrictive pericarditis SIGNS & SYMPTOMS ▪ Clinical presentation nonspecific, related to underlying cause, reflecting impaired cardiac function ▪ Diminished heart sounds ▪ Jugular vein distention ▪ Tachycardia, dyspnea, decreased blood pressure, lightheadedness 104 OSMOSIS.ORG TREATMENT MEDICATIONS ▪ Relieve pain, treat underlying cause of inflammation SURGERY ▪ Pericardiocentesis