Flashcards in Pericardial disease Deck (19)
Describe the anatomy of the pericardium
The pericardium is a protective covering for the heart that confines its position in the mediastinum.
Visceral: inner serious membrane made of a single layer of mesothelial cells.
Parietal: outer membranes lines the fibrous sac.
Pericardial fluid (normal 20-49ml) drains via the thoracic duct and right lymphatic duct into the right pleural space.
List the presentations of pericardial disease
Acute and relapsing pericarditis
Pericardial effusion and cardiac tamponade
Describe the symptomsof acute pericarditis
Like pleurisy: Sharp, worse on inspiration
Like angina: Central chest pain, radiating to shoulder
Specific: Relieved by sitting forward
Viral/bacterial, rheumatic fever or MI:
-Usually fever, leucocytosis or lymphcytosis
Pericardial effusion/tamponade: Dyspnoea
List 5 causes of acute pericarditis
Majority are idiopathic
Viral*: esp Coxsackievirus, painful but shortlived
Bacterial: Staph aureus is a frequent cause of purulent pericarditis in HIV patients, pneumonia
Tuberculosis: acute pericarditis + chronic low-grade fever, dyspnoea, night sweats, weight loss
Post-MI pericarditis: 20% of MI in first few days
Dressler syndrome: autoimmune response at 2-10wk
Malignant pericarditis: Mesothelioma, Carcinoma of bronchus/breast, Hodgkin's lymphoma
Uraemic pericarditis: 35-50% of patients with uraemia and CKD. Indication for urgent dialysis.
Autoimmune: RA, rheumatic fever, SLE, scleroderma etc
Describe the signs of acute pericarditis
Tachycardia, tachypnoea, fever
Pericardial friction rub: best heard with diaphragm at LSE with patient leaning forwards, at end of expiration
Loud high-pitched S3 (pericardial knock)
-Right heart failure: raised JVP, ascite, hepatomegaly, Kussmaul sign
-Hypotension, pulsus paradoxus
Which investigations help diagnose acute pericarditis?
FBC, U&Es, LFTs, CRP, CK, TnI
ECG is diagnostic*:
-Widespread saddle ST elevation
-Reciprocal ST depression in leads aVR and V1
-PR segment depression
CXR and echo: pericardial effusion
CT/MRI: thickened or inflamed pericardium
What additional investigations help find the aetiology of acute pericarditis?
Sputum for acid-fast bacilli
Outline the management of acute pericarditis
Treat any known underlying causes
Bed rest and oral NSAIDs
-High-dose aspirin, indometacin, or ibuprofen
-Aspirin post-MI: NSAID risk of myocardial rupture
Define pericardial effusion and cardiac tamponade
Pericardial effusion: an abnormal accumulation of fluid within the potential space of the pericardial cavity. Commonly accompanies an episode of acute pericarditis.
Cardiac tamponade: Large pericardial effusion that compromises ventricular filling. This results in reduced CO, hypotension, and shock.
Name 3 causes of acute pleural effusion
Iatrogenic: cardiac surgery, catherisation, anticoagulant
Aortic dissection (Type A)
Cardiac rupture post-MI: think NSAIDs
Name 3 causes of sub-acute pleural effusion
Infection (bacterial, viral, TB)
Describe the clinical features of pleural effusion and cardiac tamponade
If slow fluid accumulation: Dyspnoea, cough, dysphagia
What signs are seen with cardiac tamponade?
-Muffled heart sounds
Kussmaul's sign: JVP increases on inspiration
Pulsus paradoxus: SBP, pulse decrease on inspiration
How is pericardial effusion/cardiac tamponade investigated?
Echo: heart wobbles in pericardial effusion
ECG: low-voltage QRS complexes
CXR: large, globular heart, without pulmonary vein distension (unlike LV failure)
Pericardiocentesis: aspiration if TB, malignancy, or bacterial pericarditis (purulent) suspected
Pericardial Bx: TB still suspected when pericardiocentesis is not diagnostic
How is pericardial effusion/cardiac tamponade managed?
Treat any underlying causes*
Most pericardial effusions resolve spontaneously
Cardiac tamponade is a medical emergency*:
-ABC, IV access and fluids, ECG, bloods, senior help
Pericardiocentesis to relieve pressure: USS or blind
-send fluid for microbiology and cytology
Pericardial drain enables temporary fluid release
Pericardial window if effusion re-accumulates: allows slow release of fluid into nearby tissues.
Which causes of acute pericarditis result in constrictive pericarditis?
Rheumatic heart disease
Define constrictive pericarditis
Pericardium becomes thick, fibrous, and calcified to the point that it interferes with diastolic filling.
Name one differential diagnosis of constrictive pericarditis