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A Review of Pericardial Diseases: Clinical, ECG and Hemodynamic Features and Management

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A Review of Pericardial Diseases: Clinical, ECG and Hemodynamic Features and Management REVIEW SHAM IK AIKAT, MD SASAN GHAFFARI, MD Department of Cardiology, Cleveland Clinic Department of Cardiology, Cleveland Clinic A review of pericardial diseases: Clinical, ECG and hemodynamic features and management ABSTRACT ECAUSE PERICARDIAL DISEASES are com- mon and often misdiagnosed, physi- Pericardial diseases are common, have multiple causes, and cians need to he familiar with their presenta- are often misdiagnosed. Physicians need to recognize the tions and distinguishing features. characteristic and distinguishing features of the three most This article reviews the clinical features, important pericardial conditions: acute pericarditis, cardiac diagnosis, and management of acute pericardi- tamponade, and constrictive pericarditis. In these tis, cardiac tamponade, and constrictive peri- conditions, proper diagnosis and appropriate management carditis. can significantly reduce morbidity and mortality. • THE PERICARDIUM KEY POINTS The pericardium envelopes the heart, extend- ing on to the adventitia of the great vessels. It Acute pericarditis is an important part of the differential is 1 to 2 mm thick and consists of an outer and diagnosis of chest pain syndromes and needs to be an inner layer. The tough, fibrous outer layer is distinguished from acute myocardial infarction both called the parietal pericardium, and the serous clinically and electrocardiographically. inner layer is called the visceral pericardium. The parietal and visceral pericardium are sep- Suspect pericardial tamponade in any patient with acute arated by fluid: 15 to 50 mL of an ultrafiltrate dyspnea, especially in the presence of a pericardial rub, of plasma that acts as a lubricant.1-2 elevated jugular venous pressure, and hypotension. The pericardium limits excessive cardiac movement and acute cardiac distension. By providing a nondistendible outer layer, it gen- Two-dimensional echocardiography with Doppler is erates a negative intrapericardial pressure dur- essential for a rapid and accurate confirmation of ing inspiration, which contributes to chamber pericardial tamponade and for safe and effective filling and establishes ventricular interdepen- therapeutic pericardiocentesis. dence in maintaining parity between right and left heart filling and cardiac output. In addi- Constrictive pericarditis is often a diagnostic challenge and tion, the pericardium acts as a barrier to infec- requires a high index of clinical suspicion. Elevated jugular tion and the extension of cancer. venous pressures distinguish it from primary liver disease, but echocardiography, magnetic resonance imaging, • ACUTE PERICARDITIS computed tomography, hemodynamic studies, and even endomyocardial biopsy are often needed. Acute pericarditis is common, but its true inci- dence is not precisely known because it often goes unrecognized and has a self-limiting course. In different autopsy series, pericarditis CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 12 DECEMBER 2000 903 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. PERICARDIAL DISEASES AIKAT AND GHAFFARI TABLE 1 Idiopathic. In most cases of acute peri- carditis the cause is unknown. A Spanish Causes of acute pericarditis study6 followed 100 consecutive patients Idiopathic admitted to a university hospital because of acute pericarditis, and the investigators were Infection able to determine a cause in only 22%. Viral: coxsackievirus B (most common viral cause), Viral infections. Patients with idiopathic coxsackievirus A, echovirus, human immunodeficiency virus pericarditis are often thought to have been Bacterial: Staphylococcus aureus, Pneumococcus species, infected by a cardiotropic virus such as cox- Mycoplasma Mycobacterial: tuberculosis (most common cause worldwide) sackievirus B. Other known viral pathogens are Fungal: Histoplasma, Aspergillus echovirus 8, mumps, influenza, and Epstein- Protozoal: Toxoplasma Barr virus. However, investigations to prove a Other: Rickettsia, anaerobes, parasites viral cause, even in patients with a typical viral prodrome, have an extremely low yield.7 Malignancy Secondary neoplasms (common): breast, lung, lymphoma, Neoplastic pericardial involvement is leukemia, melanoma seen at autopsy in up to 10% of patients with Primary neoplasms (rare): pericardial mesothelioma, a known malignancy.7 The most common angiosarcoma malignancies that affect the pericardium are lung and breast cancers, melanomas, lym- Connective tissue disease phomas, and leukemias. Primary pericardial Systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, scleroderma tumors are rare and usually take the form of benign pericardial cysts.5-7'8 Myocardial infarction Radiation therapy Symptoms and signs of acute pericarditis Chest pain is the cardinal symptom of Cardiac surgery acute pericarditis. The pain: Uremia • Is often located retrosternally or precor- Myxedema dially • Is sharp, knifelike, and pleuritic Aortic dissection • Worsens with inspiration and in the Drugs (as part of drug-induced systemic lupus erythematosus) supine position Hydralazine • Is relieved on sitting and leaning forward Methyldopa • Sometimes alters or recurs with each beat Procainamide of the heart Others: cromolyn sodium, doxorubicin, penicillin • Can radiate to the left shoulder, the arm, neck, back, or epigastric region. Radiation ADAPTED FROM REFERENCES 1,5,7,8,24 of the pain to the trapezius ridge is an uncommon but specific sign of acute peri- carditis.5 was detected in 2% to 6% of the sample Dyspnea is the other prominent symp- groups. Acute pericarditis is estimated to be tom, though not always present. clinically present in 1 of every 1,000 hospital- Other symptoms may include fever, ized patients.4 cough, hoarseness, nausea, vomiting, palpita- Acute pericarditis runs a time course of tions, dizziness, and lightheadedness. Certain less than 6 weeks. If pericarditis lasts 6 weeks symptoms depend on the cause of the peri- to 6 months, it is termed "subacute."4 It is con- carditis: eg, flulike symptoms (fever, myalgias) sidered chronic when it has been present 6 in viral pericarditis or a fulminant and rapid months or longer.4 course with prominent systemic septic features in purulent bacterial pericarditis. Chronic Causes of acute pericarditis cough, history of weight loss, night sweats, and Inflammation of the pericardium has a variety generalized malaise may represent tuberculous of causes (TABLE 1). pericarditis. 904 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 2 DECEMBER 2000 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. Acute pericarditis progresses through stages Stage 1 begins with the onset of chest pain, and lasts several days. Note the concave upward ST elevations seen in the precordial and limb leads. The T waves remain upright in those leads with ST-segment elevation. Stage 2. The ST segments return to the baseline, T waves become flat, and the PR segment may become depressed. II aVL ~V2 I I 1 V5 Stage 3. T-wave inversion may be seen. This may persist for weeks, or even indefinitely. Stage 4. Normalization. FIGURE 1. The electrocardiographic stages of acute pericarditis A friction rub is the pathognomonic sign changes in acute pericarditis (FIGURE I).5>8 of acute pericarditis. This is a scratchy, superfi- Note: the first stage is dominated by ST- cial, "Velcro-like" sound, best heard with the segment elevation, which can also be seen in diaphragm of the stethoscope applied firmly to acute myocardial infarction or early repolar- the left lower sternal border with the patient ization. It is vital to distinguish between acute leaning forward and momentarily holding his or myocardial infarction and acute pericarditis, her breath at end-expiration. The rub is often since thrombolytic therapy can result in hem- evanescent and may be triphasic, having an orrhagic cardiac tamponade in patients with atrial systolic, a ventricular systolic, and a dias- pericarditis. The distinction can be difficult. tolic component.'' It is uncommon for all three Important differentiating features are outlined phases to be present; often only a monophasic in TABLE 2 and FIGURE 2. or biphasic rub may be heard. When an effusion Chest radiography may be normal, but develops, the rub may become subdued or may the cardiac silhouette may be enlarged if even disappear, but occasionally the rub persists enough fluid (at least 200-250 mL) accumu- even when the effusion is large. lates in the pericardial sac.1'9 Echocardiography. A pericardial effusion Diagnostic studies for acute pericarditis may accompany acute pericarditis. The pres- Electrocardiography. Serial electrocar- ence of a significant effusion or accumulation diograms commonly show four stages of of an effusion on serial echocardiographic 880 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 2 DECEMBER 2000 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. PERICARDIAL DISEASES AIKAT AND GHAFFARI TABLE 1 Electrocardiographic features of acute pericarditis, acute myocardial infarction, and early repolarization ELECTROCARDIOGRAPHIC ACUTE PERICARDITIS ACUTE MYOCARDIAL EARLY REPOLARIZATION FEATURE INFARCTION ST-segment concavity Upward Downward Upward Loss of R wave, Absent Present Absent presence of Q wave, reciprocal changes Location of Limb and precordial leads In leads corresponding Precordial leads ST-segment elevation (except Vv aVR) to the infarct territory PR-segment
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