Pericardial Disease (Pericarditis and Pericardial Tamponade)

Chapter 31 Pericardial Disease (Pericarditis and Pericardial Tamponade)



Stuart F. Sidlow, MD , C. William Hanson, III , MD




1 What is the structure of the pericardium?


The pericardium is a two-layered structure surrounding the heart and consisting of the fibrous and serous layers. The fibrous layer is a stiff, inelastic structure, which has little ability to accommodate fluid accumulation over a short time course. The serous layer consists of two layers, the parietal and visceral pericardium. The parietal layer is adherent to the fibrous pericardium, and the visceral layer is part of the epicardium or external layer of the heart wall. When pericardial effusion occurs, it normally is between the parietal and visceral layers of the serous pericardium. The pericardial space normally holds 15 to 50 mL of an ultrafiltrate of plasma.



2 Why do hemodynamic changes occur with the buildup of fluid between the layers of the serous pericardium?


When fluid accumulates in the pericardial space, the fibrous pericardium has little ability to stretch. As the volume increases in this space, further inflow into the right side of the heart is impaired, which results in decrease in filling of the left side of the heart, and thus preload is decreased.



3 What general types of pericardial disease exist?




image Acute fibrinous pericarditis (acute pericarditis)


image Pericardial effusion without hemodynamic compromise


image Cardiac tamponade


image Constrictive pericarditis



4 What are the major causes of acute pericarditis (greatest to least common)?




image Neoplastic or radiation


image Viral-adenovirus, enterovirus, cytomegalovirus, influenza, hepatitis B virus, herpes simplex virus


image Autoimmune or collagen vascular disease


image Bacterial


image Uremia


image Tuberculosis (TB) (most common worldwide)


image Idiopathic


image Drugs or toxins



5 Describe the clinical manifestation of acute pericarditis (history and physical examination)


Patient may complain of pleuritic chest pain worse on inspiration. Pain is exacerbated by supine position and relieved by sitting up. Dyspnea may be present. A pericardial friction rub is highly specific to acute pericarditis. Many are seen initially with high fever (temperature > 38° C) and new cardiomegaly on chest radiograph. Pleural effusions are frequently observed.



6 What is on the differential diagnosis of acute pericarditis?


Differential diagnosis of acute pericarditis consists of acute myocardial infarction, pulmonary embolus, gastroesophageal reflux, and musculoskeletal pain.



7 How is acute pericarditis manifested on electrocardiography (ECG)?


There is a progression of four stages on ECG, but for diagnosis one should evaluate for concave-up ST segments throughout most leads (exceptions include aVR and V1).



8 What other diagnostic tests are useful in diagnosis of acute pericarditis?


Serum cardiac troponin I and creatine kinase, myocardial bound (CKMB) levels should be evaluated. Usually mild troponin increases occur in the absence of increased CKMB levels. The increase is due to inflammation of myocardium. Other tests may include (on the basis of suspicion and other findings) antinuclear antibodies, tuberculin skin test, human immunodeficiency virus serology, and blood cultures.



9 How is pericardiocentesis used in diagnosing or treating acute pericarditis?


Pericardiocentesis or surgical drainage should be performed for one of three reasons:



image If moderate to severe tamponade is present, resulting in hemodynamic compromise (class I recommendation)


image If purulent, TB or neoplastic effusion is suspected (class IIa recommendation)


image If a persistently symptomatic effusion is present



10 Does echocardiography play a role in the diagnosis of acute pericarditis?


Echocardiography should be performed in all patients suspected of having acute pericarditis. The echo is often normal, but when an effusion is seen it supports the diagnosis of acute pericarditis. The absence of effusion does not rule it out. The use of echocardiography was given a class I recommendation by the American Heart Association, American College of Cardiology, and American Society of Echocardiography.

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Pericardial Disease (Pericarditis and Pericardial Tamponade)

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