Pericarditis Disease

DESCRIPTION

The clinical manifestations of disease processes involving the pericardial sac surrounding the heart

Acute pericarditis: an inflammatory process of the pericardium from a wide spectrum of etiologies, with or without associated effusion. The most common etiology is idiopathic or nonspecific pericarditis.
Pericardial tamponade: cardiac compression from pericardial effusion causing hemodynamic compromise and disruption of compensatory mechanisms
Constrictive pericarditis: thickening and adherence of the pericardium to the heart after chronic inflammation
System(s) affected: Cardiovascular
Genetics: Unknown
Incidence/Prevalence in USA: 2% penetration trauma develop tamponade
Predominant age: Adolescents and young adults
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

Acute pericarditis
- Chest pain, typically sharp, retrosternal with radiation to the trapezial ridge
- Pain frequently sudden in onset, with inspiration or movement
- Pain reduced by leaning forward and sitting up
- Splinted breathing
- Odynophagia
- Fever
- Myalgia
- Anorexia
- Anxiety
- Pericardial friction rub
- Cardiac arrhythmias often intermittent, supraventricular tachycardia (SVT)
- Tachypnea
- Localized rales
Pericardial tamponade
- Dyspnea
- Tachycardia
- Distended jugular neck veins
- Cyanosis
- Relative or absolute hypotension
- Quiet precordium with little palpable cardiac activity
- Pericardial friction rub
- Lungs clear
- Ewart's sign – dullness and bronchial breathing between the tip of the left scapula and vertebral column
- Rapid thready pulse
- Varying degrees of consciousness
- Pulsus paradoxus: > 10 mm Hg (1.33 kPa) decrease in systolic pressure with inspiration
- Beck's triad – distended neck veins, hypotension, and muffled heart sounds
Constrictive pericarditis
- Asymptomatic, early
- Dyspnea, pulmonary congestion
- Fatigue very common
- Peripheral edema
- Hepatomegaly
- Ascites
- Jugular venous distention – elevated, deep Y trough (not seen in tamponade)
- Kussmaul's sign – inspiratory increase in jugular venous pressure
- Pericardial “knock” – follows S₂ by 0.06–0.12 sec, increases with squatting
- Hypovolemia may mask the signs of constriction

CAUSES

Idiopathic
Viral: Coxsackie, echo, adenovirus, Epstein-Barr, mumps
Bacterial: Haemophilus (especially children), Staphylococcus, Pneumococcus, Salmonella, Meningococcus, Lyme disease, Legionella, Mycoplasma
Fungal: Candida, Histoplasmosis, Aspergillus, Nocardia
Mycobacterial: Mycobacterium tuberculosis
Parasites, protozoa
Neoplastic: breast, lung, lymphoma, mesothelioma
Drug-induced: procainamide, hydralazine, bleomycin, phenytoin, minoxidil, mesalamine, azathioprine, and perhaps others
Connective tissue disease: systemic lupus erythematosus, rheumatoid arthritis, scleroderma, acute rheumatic fever
Radiation
Myocardial infarction, Dressler's syndrome
Postpericardiotomy
Uremia
Myxedema
Cholesterol pericarditis
Aortic dissection
Sarcoidosis
Pancreatitis
Inflammatory bowel disease
AIDS
Chylopericardium
Familial – autosomal recessive (Mulibrey nanism)

RISK FACTORS

Chest trauma

LABORATORY

Leukocytosis and increased ESR
May see elevated creatine kinase (CK), lactate dehydrogenase (LDH), serum glutamic-oxaloacetic transaminase (SGOT)

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Micro: acute inflammation

SPECIAL TESTS

4 stages in pericarditis

Electrocardiogram – electrical alternans in tamponade
Echocardiogram – determines fluid, right atrial (RA) or right ventricular (RV) collapse
Right heart catheterization – equalization of mean and diastolic pressures in all waveforms

IMAGING

Chest x-ray – small pleural effusion, transient infiltrates; “water bottle” silhouette in large associated pericardial effusion
Chest CT or MRI in suspected constrictive pericarditis may reveal calcified or thickened pericardium and delineate effusions

DIAGNOSTIC PROCEDURES

Pericardiocentesis
Pericardial biopsy

APPROPRIATE HEALTH CARE

Outpatient unless signs of complications
Inpatient with complications (hemodynamic compromise or effusion present)

GENERAL MEASURES

N/A

SURGICAL MEASURES

Pericardiectomy may be required if drugs are not effective

ACTIVITY

No restrictions; limited by patients symptoms only

DIET

No restriction. If patient overweight, suggest a weight loss program.

PATIENT EDUCATION

Since 15% of patients have a recurrence, must educate for return of symptoms and followup

PREVENTION/AVOIDANCE

Follow up patients in the office in 2 weeks and re-evaluate cardiac status and symptomatology
Repeat chest x-ray and electrocardiogram should be considered at 4 weeks

POSSIBLE COMPLICATIONS

Pericardial tamponade
Recurrence of pericarditis
Non-compressive effusion
Chronic, constrictive pericarditis

EXPECTED COURSE AND PROGNOSIS

The majority of patients have complete resolution of pain and symptoms during the 2 weeks of therapy
Fifteen percent will have at least one recurrence in the first few months
A rare patient may become refractory and require corticosteroids or pericardiectomy
The hemodynamic effects of effusions depend on the volume and rapidity of development
A very small percentage of patients can develop signs of right-sided heart failure secondary to constriction. These patients are best treated with pericardiectomy.

ASSOCIATED CONDITIONS

Dependent on etiology

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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