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Pericardial diseases (Ref. Hari. 18th ed., Pg - 1971)

Acute pericarditis

 

Inflammation of the pericardium which may be primary or secondary to systemic disease.

 

Causes:

  1. Viruses (Coxsackie, Epstein-Barr, mumps, varicella, HIV)
  2. Bacteria (pneumonia, rheumatic fever, TB)
  3. Fungi
  4. Myocardial infarction, Dressler's syndrome
  5. Drugs procainamide, hydralazine.
  6. Others: uraemia, Rheumatoid arthritis, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy.

Causes of haemorrhagic pericarditis: (Ref. Robbins 7th ed., pg -  601, 602)

  1. Bacterial infections: infective endocarditis                       
  2. Tuberculosis
  3. Bleeding diathesis                                          
  4. Following cardiac surgery   
  5. Ruptured MI                                          
  6. Ruptured aortic dissection
  7. 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

 

Tests:

 

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.


Causes
:

  1. Unknown        
  2. TB (commonest) Q           
  3. After any pericarditis.

Important Points: Constrictive pericarditis does not occur in rheumatic pericarditis (FAQ).

 

Clinical features:

  1. These are mainly of right heart failure with raised JVP;
  2. Kussmaul's sign Q (LQ 2012) is positive (JVP rising paradoxically will inspiration);
  3. Prominent Y descent,
  4. Prominent X descent Q
  5. Diastolic pericardial knock Q, is present,
  6. Hepatosplenomegaly, ascites, and oedema,
  7. Retractile apex beat (broadbend sign)
  8. Nephrotic syndrome can occur (LQ 2012)
  9. 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:

  1. CP  
  2. RV infarct
  3. Restrictive CM
  4. TS  
  5. Advanced LV systolic failure    
  6. Massive pulmonary embolism.

Important points

  1. Ascites is out of proportion to oedema in CP.
  2. Acute pulmonary oedema is not a feature of CP.

DD: Cirrhosis of liver Q (Because of associated ascites. Splenomegaly)

 

Tests:

  1. CXR: small heart pericardial calcification (if none, CT/MRI helps distinguish from other cardiomyopathies).
  2. Echo; will show thickened pericardium
  3. Cardiac catheterization reveals ventricle diastolic pressure shows square root sign or deep and plateau sign. 

Complications

  1. Nephrotic syndrome Q
  2. 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;.

 

Signs:

  1. Increase Pulse rate,
  2. Low BP, pulsus paradoxus Q,
  3. Raised JVP,
  4. Muffled heart sound.
  5. Ewart sign is positive Q  (LQ 2012)
  6. S3 is absent Q,
  7. Y descent is never prominent Q (AIIMS Nov 10)
  8. X descent is prominent.
  9. Ewart's sign: large effusion compressing left lower lobe. Look for signs of cardiac tamponade. 

Diagnosis:

 

Beck's triad:

  1. Falling BP;                
  2. Rising JVP;           
  3. Small, quiet heart. (AIIMS May 2010)   

Investigation:

  1. CXR big globular heart.
  2. ECG: low voltage Q, electrical alternans Q.
  3. Echo is diagnostic: echo-free zone around the heart
  4. Cath:  diastolic collapse of right atrium and right ventricle. Q

Important Points: Equalization of diastolic pressure occurs in both CP and CT


Management
:

  1. The pericardial effusion needs urgent drainage.
  2. Treat the basic cause.

Table 239-2 Features that Distinguish Cardiac Tamponade from Constrictive Pericarditis and Similar Clinical Disorders Disorders (Ref. Hari. 18th ed., pg - 1975, Table 239-2)

Characteristic

Tamponade

Constrictive Pericarditis

Restrictive Cardiomyopathy

RVMI

Clinical

 

 

 

 

Pulsus paradoxus

Common

Usually absent

Rare

Rare

Jugular veins

 

 

 

 

Prominent y descent

Absent

Usually present

Rare

Rare

Prominent x descent

Present

Usually present

Present

Rare

Kussmaul's sign

Absent

Present

Absent

Present

Third heart sound

Absent

Absent

Rare

May be present

Pericardial knock

Absent

Often present

Absent

Absent

Electrocardiogram

 

 

 

 

Low ECG voltage

May be present

May be present

May be present

Absent

Electrical alternans

May be present

Absent

Absent

Absent

Echocardiography

 

 

 

 

Right atrial collapse and RVDC

Present

Absent

Absent

Absent

Increased early filling, mitral flow velocity

Absent

Present

Present

May be present

Cardiac catheterization

 

 

 

 

Equalization of diastolic pressures

Usually present

Usually present

Usually absent

Absent or present





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