Pericardial Diseases

Question 1

Pericardium is composed of …

Answer 1

Two layers:

1. Visceral pericardium
2. Parietal pericardium

Question 2

Describe how the visceral pericardium is composed:

Answer 2

• Membrane composed of single layer mesothelial cells
• Similar to pleural and peritoneal cavity
• Adherent to the epicardial surface of the heart

Question 3

Describe how the parietal pericardium is composed:

Answer 3

• Fibrous layer 2mm in thickness
• Contains collagen and elastic fibers
• Collagen:
  
  1. Low levels of stretch ⇒ Wavy bundles
  2. High levels of stretch ⇒ Streight bundles
• Reflects the mechanical characteristics of the pericardial tissue

Question 4

The visceral pericardium reflects back near the origin of the _____ ______ and becomes the ______ ________.

• How much serous fluid is in the pericardial space in a healthy individual?

Answer 4

The visceral pericardium reflects back near the origin of the great vessels and becomes the parietal pericardium.

• Pericardial space
  
  • Contains ≈ 15 - 50ml serous fluid in a healthy individual

Question 5

What stabilizes the pericardium?

Answer 5

Stabilized by ligamentous attachements

1. Diaphragm
2. Sternum
3. Spine

Question 6

Phrenic nerves are enveloped by _______ __________.

• What happens if the phrenic nerve is irritated?

Answer 6

Phrenic nerves are enveloped by parietal pericardium.

• Phrenic nerve irritation ⇒ hiccups

Question 7

What are the major functions of the pericardium?

Answer 7

• Maintains heart position
• Lubrication of visceral and parietal layers
• Barrier to infection
• Prostaglandin secretion
  
  • Modulation of coronary vascular tone
• Restraining effect on cardiac volume

Question 8

• What is the restraining effect of the pericardium?
  
  • How does the pericardium respond to increased cardiac volumes?

Answer 8

1. Restraining effect on cardiac volume
   
   • Mechanical properties of pericardial tissue
   • Small reserve volume
   • Tensile strength similar to rubber
   • Normal cardiac volume
     
     • More elastic ⇒ stretches easily
   • When there is increased cardiac volumes:
     
     • Pericardial tissue becomes stiff ⇒ resistant to further stretch

Question 9

How is the Pericardial Pressure Volume Curve practically significant in pericardial effusions?

Answer 9

Practical significance in pericardial effusions

• Once critical volume of effusion is reached small additional amounts ⇒ large increase of intrapericardial pressure
• Removal of small amount of fluid ⇒ significant improvement of pressure

Question 10

Acute vs chronic cardiac dilatation

Answer 10

• Chronic cardiac dilatation results in adaptations to accomodate increased cardiac volumes
• Pericardial growth occurs in response to chronic stretch
• Pressure volume curve shifts to the right with decreased slope
• Slowly accumulating pericardial effusions can become very large before becoming symptomatic (Hypothyroidism)

Question 11

What is the major cause of acute pericarditis?

Answer 11

• Majority (80-90%) of cases “Idiopathic”
  
  • No specific etiology identified with routine diagnostic testing
  • Most acute “Idiopathic” cases are assumed to be viral in etiology
  • Routine testing for specific viral agents not done

Question 12

What are other causes of acute pericarditis?

Answer 12

1. Infectious
   
   • Viral (Echo/Coxsackie/Adenovirus, CMV, HIV)
   • Bacterial(Pneumococcus/Strep/staph/mycoplasma/haemophilus)
   • Myobacteria (MT/MAI)
2. Radiation (Acute and chronic)
3. Blunt and penetrating trauma
4. Connective tissue disorders
   
   • SLE, RA, Systemic sclerosis
5. Post MI, and Dressler syndrome

Question 13

What is the classic presentation of acute pericarditis?

Answer 13

• Chest pain
  
  • Almost always present
  • Usually moderate to severe in intensity
  • Better sitting forward, worse when lying down
  • Sharp, pleuritic like
  • Substernal, epigastric, left chest, trapezius muscle area (specific for pericarditis)
• Can be associated with dyspnea, cough, hiccups, fever

Question 14

Differential diagnosis of CP in pericarditis:

Answer 14

1. Pneumonia with pleurisy (Pleuro-pericarditis)
2. PE with infarction
3. Costochondritis
4. GERD
5. Intraabdominal processes
6. Aortic dissection
7. Pneumothorax
8. Herpes Zoster (Before skin lesions)
9. Myocardial ischemia/infarction
   
   • Presenting manifestation of clinically silent MI

Question 15

What can be found upon physical examination on a patient with acute pericarditis?

Answer 15

• Uncomplicated acute pericarditis
• Fever, tachycardia, anxiety (Not always present)
• Pericardial friction rub

Question 16

Describe the pericardial friction rub in acute pericarditis:

Answer 16

• Contact between parietal and visceral
• Usually three components
  
  • Ventricular Systole, diastole, atrial contraction
• Best heard at left LSB, w/ patient leaning forward
• Dynamic (Similar to ECG findings)
• Disappearing/returning over short periods of time
• Frequently exam when suspecting pericarditis without audible rub
• One or two component rub can represent mumurs (Use Caution)

Question 17

What are the ECG findings in acute pericarditis?

Answer 17

• ECG changes are dynamic (Like rub)
• ST segment elevation
  
  • Diffuse (Not in leads AVR,V1)
  • Occasionally focal (Trauma and post-op)
  • ST segment concave
  • No reciprocal changes
• Upright T waves
• PR depression (Elevation in AVR)
  
  • PR depression may be only ECG finding

Question 18

What are additional ECG findings in acute pericariditis?

Answer 18

1. Low voltage QRS
2. Electrical alternans
   
   • Secondary to pericardial effusion

Question 19

What are some potential lab findings in acute pericarditis?

Answer 19

1. Idiopathic “Viral” pericarditis
   
   • Mild elevation of WBC count with lymphocytosis
   • Mild elevation of ESR
2. Consider Secondary Etiologies:
   
   • Significant WBC elevation with left shift
   • Anemia, elevated ESR (Connective tissue disorders)
   • Elevated ESR (Connective tissue disorders, TB)

Question 20

What can be found on CxR in complicated acute pericarditis?

Answer 20

Abnormal CXR findings consided 2ry disorders

1. Pleural effusions
2. Infilrates
3. Mass lesions
4. CHF

Question 21

Why is an echocardiogram used in a patient with acute pericarditis?

Answer 21

• Not required for diagnosis and management of idiopathic pericarditis
• Small otherwise clinically silent effusion not uncommon
• Large effusion consider secondary disorder
• LV function assessment in pt with myocarditis
• Check for WMA if ischemia/MI suspected

Question 22

What is used to treat “idiopathic” acute pericarditis?

Answer 22

• Uneventful recovery in 70% - 90% of patients

1. Treatment with NSAIDS (Post MI use aspirin)
2. Colchicine
   
   • With NSAIDS
   • Alternative to NSAIDS
   • Decreased incidence of recurrent pericarditis
   • Discontinuation rate 10%-15% (GI side effects)
3. Steroids
   
   • Rapid response to treatment
   • Corticosteroids may encourage relapses (Avoid if possible)

Question 23

What does colchicine act on?

Answer 23

• Inhibits the process of microtubule self-assembly
  
  • This takes place either in the mitotic spindle or in the interphase stage
• Inhibits movement of intercellular granules and the secretion of various substances in leucocytes
• Significant anti-inflammatory action
• Colchicine has preferential concentration in leukocytes
• Peak concentration of colchicine may be 16 times the peak concentration in plasma

Question 24

What was the conclusion of the COPE trial?

Answer 24

Conclusion of the COPE trial:

• Colchicine + coventional therapy led to clinically important and statistically significant benefit over conventional treatment
  
  • decreasing the recurrence rate in patients with a first episode of acute pericarditis
• Corticosteroid therapy given in the index of attack can favor the occurence of recurrences

Question 25

How is **acute pericarditis diagnosed**?

Answer 25

**Two of the following criteria:** 1. **Typical chest pain** (sharp and pleuritic, improved by sittng up and leaning forward); 2. **Pericardial friction rub** 3. **Suggestive changes of on ECG** (widespread ST-segment elevation or PR depression) 4. New or worsening **pericardial effusion**

Question 26

What is "incessant" pericarditis?

Answer 26

diagnosis of incessant pericarditis: * patients with persistent pericarditis or * those with symptom-free intervals of less than 6 weeks duration

Question 27

**Specific Causes of Pericardial Disease: ** Noninflammatory Conditions

Answer 27

* **Hydropericardium** is an _accumulation of serous transudate in the pericardial space_ * Associated with congestive heart failure, hyponatremia or chronic kidney or liver diseases; * **Hemopericardium** is an _accumulation of blood in the pericardiac sac_ * Trauma of either the heart or aorta * Myocardial rupture after acute MI

Question 28

How is HIV involved in pericardial disease?

Answer 28

* More common pre-HAART * _20% of HIV patients_ develop pericardial involvement * _Pericardial effusion most common cardiac manifestation of HIV infection_ * Seen in more _advanced stages_ of the disease * Presence of pericardial effusion associated with X9 greater 6 month mortality (independed of CD4 count) * Most effusions are small, asymptomatic, and idiopathic * Generalized sero-effusive process (“Capillary leak” syndrome) * **Large effusions usually secondary to:** * Infection (MT, MAI, CMV, Cryptococcus) * Neoplasm (Kaposi sarcoma, lymphomas) * **Treatment** * Identification of underlying etiology