Pericardial diseases (Ref. Hari. 18th ed., Pg - 1971)
Inflammation of the pericardium which may be primary or secondary to systemic disease.
- Viruses (Coxsackie, Epstein-Barr, mumps, varicella, HIV)
- Bacteria (pneumonia, rheumatic fever, TB)
- Myocardial infarction, Dressler's syndrome
- Drugs procainamide, hydralazine.
- Others: uraemia, Rheumatoid arthritis, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy.
Causes of haemorrhagic pericarditis: (Ref. Robbins 7th ed., pg - 601, 602)
- Bacterial infections: infective endocarditis
- Bleeding diathesis
- Following cardiac surgery
- Ruptured MI
- Ruptured aortic dissection
- Traumatic perforation
Clinical features: Central chest pain worse on inspiration or lying flat, relief by leaning forward.
A pericardial friction Q rub may be heard
ECG classically shows concave (saddle-shaped) ST segment elevation Q, but may be normal or non-specific
Constrictive Pericarditis (CP)
The heart is encased in a rigid pericardium.
- TB (commonest) Q
- After any pericarditis.
Important Points: Constrictive pericarditis does not occur in rheumatic pericarditis (FAQ).
- These are mainly of right heart failure with raised JVP;
- Kussmaul's sign Q (LQ 2012) is positive (JVP rising paradoxically will inspiration);
- Prominent Y descent,
- Prominent X descent Q
- Diastolic pericardial knock Q, is present,
- Hepatosplenomegaly, ascites, and oedema,
- Retractile apex beat (broadbend sign)
- Nephrotic syndrome can occur (LQ 2012)
- Protein loosing enteropathy is a feature.
Extra Edge: Diastolic pericardial knock (it is S3) is heard in early diastole.
Extra Edge: (Ref. Hari. 18th ed., Page - 1823)
Normally, the venous pressure should fall by at least 3 mmHg with inspiration. Kussmaul's sign is defined by either a rise or a lack of fall of the JVP with inspiration.
Extra Edge: Causes of Kussmaul sign:
- RV infarct
- Restrictive CM
- Advanced LV systolic failure
- Massive pulmonary embolism.
- Ascites is out of proportion to oedema in CP.
- Acute pulmonary oedema is not a feature of CP.
DD: Cirrhosis of liver Q (Because of associated ascites. Splenomegaly)
- CXR: small heart pericardial calcification (if none, CT/MRI helps distinguish from other cardiomyopathies).
- Echo; will show thickened pericardium
- Cardiac catheterization reveals ventricle diastolic pressure shows square root sign or deep and plateau sign.
- Nephrotic syndrome Q
- Protein loosing enteropathy Q
Management: Surgical removal of the pericardia.
Cardiac tamponade (CT)
Accumulation of pericardial fluid raises intra-pericardial pressure, hence poor ventricular filling and fall in cardiac output
Causes: Any condition which cause pericarditis can cause CT; aortic dissection; hemodialysis; warfarin; transmyocardial puncture at cardiac catheterization;.
- Increase Pulse rate,
- Low BP, pulsus paradoxus Q,
- Raised JVP,
- Muffled heart sound.
- Ewart sign is positive Q (LQ 2012)
- S3 is absent Q,
- Y descent is never prominent Q (AIIMS Nov 10)
- X descent is prominent.
- Ewart's sign: large effusion compressing left lower lobe. Look for signs of cardiac tamponade.
- Falling BP;
- Rising JVP;
- Small, quiet heart. (AIIMS May 2010)
- CXR big globular heart.
- ECG: low voltage Q, electrical alternans Q.
- Echo is diagnostic: echo-free zone around the heart
- Cath: diastolic collapse of right atrium and right ventricle. Q
Important Points: Equalization of diastolic pressure occurs in both CP and CT
- The pericardial effusion needs urgent drainage.
- Treat the basic cause.