Pericardial Diseases: Pericarditis and Tamponade

DIFFERENTIAL DIAGNOSIS

Metabolic uremia, dialysis, hypothyroidism

Medications procainamide, hydralazine, INH, phenytoin, penicillin

Myocardial Infarction MI (early, late)

Infectious HIV, Coxsackie, echovirus, adenovirus, TB

Inflammatory psoriatic arthritis, enteric arthritis, rheumatoid arthritis, SLE, mixed connective tissue disease
Idiopathic

Neoplastic primary (mesothelioma), metastasis (breast, lung, melanoma), leukemia, lymphoma

Trauma stab, gunshot wound, blunt, CPR, post pericardiotomy

CLINICAL FEATURES

Rational clinical examination series: Doses this patient with a pericardial Effusion have Cardiac Tamponade?
	Sensation	Spc
History
Dyspnea	87 89%
Fever	25%
Chest pain	20%
Cough	7 10%
Physical
Tachycardia	77%
Pulsus paradoxus >10 mmHga	82%	70%
Elevated JVP	76%
Decreased  heart sounds	28%
Hypotension	26%
Hypertension	33%
Tachypnea	80%
Peripheral edema	21 28%
Pericardial rub	19 29%
Hepatomegaly	28 55%
Kussmaul sign	26%
ECG
Low voltage	42%
Atrial arrhythmia	6%
Electrical alternans	16 21%
ST elevation	18 30%
PR depression	18%
Pulsus paradoxus LR+ 3.3, LR 0.03
Approach ‘‘among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated JVP, or cardiomegaly on chest radiograph. A pulsus paradoxus >10 mmHg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing’’

Distinguishing features of acute Tamponade and chronic Constrictive Pericarditis
	Acute Tamponade	Constrictive Pericarditis
Vitals	Tachycardia, Hypotension +++, Pulsus paradoxus	Hypotension, Pulsus paradoxus (rare)
JVP	Elevated, Kussmaul (rare) Prominent x’ descent but blunted y descent	Elevated, Kussmaul Prominent x’ and y descent (Friedrich’s sign)
Apex beat	Impalpable	Impalpable
Heart sounds	Distant	Distant, early S3/knock
Other features	Dullness and bronchial breath sounds over left base (Ewart sign)	Hepatosplenomegaly, edema

INVESTIGATIONS

Basic

Labs Investigations: CBCD,eclectrolytes, urea, Cr, troponin, CK

Radiological Investigations CXR (calcification if constrictive disease), echocardiogram

ECG may have sinus tachycardia, low voltages, and electrical alternans in tamponade/effusion; diffuse ST elevation (concave up) and PR depression may be seen in Pericarditis

Special

Pericardiocentesis diagnostic or therapeutic (for tamponade, TB/bacterial pericarditis, or large persistent effusion)

Pericardioscopy

CT/MRI Chest if suspect constrictive Pericarditis

MANAGEMENT

Acute Pericarditis ASA (650 mg PO TID x3 4 weeks), NSAIDs (indomethacin 25 50 mg PO TID x 2 4 weeks). Add colchicine 0.6 mg PO BID x3 months for adjuvant treatment and long term prophylaxis. Prednisone 0.25 0.5 mg/kg PO daily may be used for connective tissue mediated disease, although symptoms may recur upon withdrawal.

Recurrent Pericarditis ASA (650 mg PO TID x4 8 weeks) or NSAIDs (indomethacin 25 50 mg PO TID 4 8 weeks). Add colchicine (0.6 mg PO BID x2 months) for adjuvant treatment and long term prophylaxis. Avoid anticoagulation as risk of hemopericardium. Prednisone 0.25 0.5 mg/kg PO daily may also be useful, although symptoms may recur upon withdrawal.

Tamponade ABC, O2, IV’s, bolus IV fluids, pericardiocentesis (subxyphoid blind approach, echocardiogram guided parasternal or apical approach), pericardiectomy, pericardial window if recurrent/malignant effusion. Avoid nitroglycerin and morphine if tampo nade as they may decrease preload, leading to worsen ing of cardiac output.

Constrictive Pericarditis complete pericardiectomy

SPECIFIC ENTITIES

Acute Pericarditis may be preceded by upper respiratory tract infection. Diagnosis is based on any two of the following inflammatory signs (LR+ 5.4): fever, pericardial friction rub (three components), characteristic chest pain (better with upright position and leaning forward, or pleuritic), PR depression, and diffuse ST elevation. Large effusion without inflammatory signs or tamponade suggests chronic idiopathic pericardial effusion (LR+ 20)

Recurrent Pericarditis returns in days to weeks upon stopping medications. Likely causes include rheumatologic disorders, Dressler’s syndrome, and post pericardiotomy syndrome

Tamponade a clinical diagnosis based on dyspnea, tachycardia, hypotension, pulsus paradoxus, and elevated JVP. Tamponade causes restriction in left or right ventricular diastolic filling. Tamponade with inflammatory signs suggests malignant effusion (LR+ 2.9)

Constrictive Pericarditis contraction of pericardium due to chronic inflammation, leading to left and/or right heart failure. May follow pericarditis or radiation. May be difficult to distinguish from restrictive cardiomyopathy clinically.