Pericardial Disease for ABIM
Pericardial Disease for the American Board of Internal Medicine Exam
Types of Pericardial Disease
Pericardial diseases encompass a range of conditions affecting the pericardium, including acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Each condition has unique clinical features and management requirements.
Acute Pericarditis
- Etiology:
- Infectious: Viral (most common; e.g., Coxsackievirus), bacterial (e.g., tuberculosis), and fungal.
- Non-infectious: Post-myocardial infarction (Dressler syndrome), uremia, autoimmune (e.g., systemic lupus erythematosus), neoplastic, radiation-induced, and drug-induced.
- Clinical Presentation:
- Chest Pain: Sharp, pleuritic pain that improves when sitting up and leaning forward.
- Fever: Common, particularly with viral or autoimmune causes.
- Pericardial Friction Rub: Classic finding, best heard at the left sternal border.
- Diagnosis:
- ECG: Diffuse ST-segment elevations and PR-segment depressions are characteristic findings.
- Echocardiogram: May reveal a small pericardial effusion but is often normal.
- Blood Tests: Elevated inflammatory markers (e.g., ESR, CRP) and leukocytosis; cardiac biomarkers may be mildly elevated.
- Management:
- NSAIDs or Aspirin: First-line treatment for symptom relief.
- Colchicine: Reduces recurrence; often added to NSAID therapy.
- Glucocorticoids: Reserved for refractory cases or contraindications to NSAIDs, as they may increase recurrence risk.
- Avoidance of Anticoagulants: To reduce risk of hemorrhagic pericardial effusion.
Pericardial Effusion
- Etiology:
- Can result from any cause of pericarditis, hypothyroidism, malignancy, trauma, or post-surgical complications.
- Can be serous, hemorrhagic, purulent, or chylous, depending on the underlying cause.
- Clinical Presentation:
- Dyspnea and chest discomfort are common; large effusions may cause dysphagia, hoarseness, or hiccups.
- May be asymptomatic if the effusion accumulates slowly.
- Diagnosis:
- Echocardiogram: Gold standard for detecting pericardial effusion; can quantify size and monitor for cardiac tamponade.
- Chest X-Ray: Shows an enlarged cardiac silhouette if the effusion is large.
- ECG: Low voltage QRS complexes and electrical alternans if large effusion is present.
- Management:
- Observation: Small, asymptomatic effusions without evidence of tamponade.
- Pericardiocentesis: Indicated if tamponade is present or if effusion is large and symptomatic.
- Treat Underlying Cause: Address any precipitating factors (e.g., uremia, infection, malignancy).
Cardiac Tamponade
- Pathophysiology: Rapid accumulation of pericardial fluid raises intrapericardial pressure, restricting ventricular filling, which reduces stroke volume and cardiac output, potentially leading to hemodynamic collapse.
- Etiology:
- Can occur with any cause of pericardial effusion, including malignancy, infection, uremia, and trauma.
- Clinical Presentation:
- Beck's Triad: Hypotension, distended neck veins, and muffled heart sounds.
- Pulsus Paradoxus: A decrease in systolic blood pressure >10 mm Hg during inspiration, indicating ventricular interdependence.
- Dyspnea, tachycardia, and fatigue: Reflect low cardiac output.
- Diagnosis:
- Echocardiogram: Key diagnostic tool; reveals diastolic collapse of the right atrium and ventricle.
- ECG: May show low voltage or electrical alternans.
- Right Heart Catheterization: Shows equalization of pressures in all chambers, though invasive and rarely required.
- Management:
- Urgent Pericardiocentesis: Immediate drainage is necessary to relieve tamponade.
- Volume Expansion and Vasopressors: Used temporarily to improve cardiac output if pericardiocentesis is delayed.
Constrictive Pericarditis
- Pathophysiology: Chronic inflammation and scarring lead to pericardial thickening and calcification, restricting diastolic filling and mimicking heart failure.
- Etiology:
- Idiopathic or Viral: Common in developed countries.
- Tuberculosis: A leading cause worldwide.
- Other: Post-surgical or radiation-induced fibrosis, autoimmune diseases.
- Clinical Presentation:
- Signs of Right Heart Failure: Peripheral edema, ascites, and hepatomegaly.
- Kussmaul’s Sign: Jugular venous pressure (JVP) increases on inspiration.
- Pericardial Knock: An early diastolic sound from abrupt cessation of ventricular filling.
- Diagnosis:
- Echocardiography: Shows septal bounce and pericardial thickening.
- CT or MRI: Can visualize pericardial thickening and calcification.
- Right Heart Catheterization: Shows “square root” sign in ventricular pressure tracings, due to rapid filling followed by early diastolic plateau.
- Management:
- Diuretics: Initial treatment to reduce volume overload.
- Pericardiectomy: Surgical removal of the pericardium is definitive for symptomatic, refractory cases.
Key Points
- Acute Pericarditis:
- Typically presents with sharp, pleuritic chest pain relieved by leaning forward.
- ECG shows diffuse ST-segment elevation and PR-segment depression.
- Treated with NSAIDs, colchicine, and occasionally corticosteroids for refractory cases.
- Pericardial Effusion:
- Can be asymptomatic or present with dyspnea and chest discomfort.
- Echocardiography is the diagnostic gold standard.
- Management includes observation for small effusions and pericardiocentesis for large or symptomatic effusions.
- Cardiac Tamponade:
- Life-threatening condition with hypotension, distended neck veins, and muffled heart sounds (Beck’s triad).
- Diagnosed by echocardiography showing chamber collapse.
- Treated with urgent pericardiocentesis; volume expansion may be used as a temporary measure.
- Constrictive Pericarditis:
- Presents with signs of right heart failure, Kussmaul’s sign, and a pericardial knock.
- Imaging (CT/MRI) shows pericardial thickening; catheterization may reveal the “square root” sign.
- Treated initially with diuretics; pericardiectomy is definitive in refractory cases.