Chapter

Pericardial disease

Michael Henein

in Oxford Textbook of Medicine

Fifth edition

Published on behalf of Oxford University Press

ISBN: 9780199204854
Published online May 2012 | e-ISBN: 9780199570973 | DOI: http://dx.doi.org/10.1093/med/9780199204854.003.1608

Series: Oxford Textbooks

Pericardial disease

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The most common clinical presentations of pericardial disease are pericarditis, effusion, tamponade, and constriction.

Acute pericarditis

The most common proven causes are viral infection or as a complication of myocardial infarction, but a wide range of other conditions including autoimmune rheumatic disorders and tuberculosis need to be considered. No firm cause is established in many cases, which are regarded as ‘idiopathic’ (presumed viral).

The main clinical features are chest pain, the presence of a pericardial rub, and widespread ST segment elevation on the ECG. Idiopathic disease is self limiting: treatment is with analgesics and/or nonsteroidal anti-inflammatory agents.

Pericardial effusion

Acute rapid collection is usually caused by traumatic injury, iatrogenic ventricular puncture, or aortic dissection. Presentation is with pericardial tamponade (see below).

Chronic fluid accumulation is most commonly caused by viral infection, uraemia, autoimmune rheumatic disease, myocardial infarction, myxoedema, or malignancy. Patients may remain asymptomatic despite the presence of a large volume of fluid in the pericardium due to corresponding increase in the capacity of the pericardial cavity. Examination may reveal distant heart sounds and increase in the area of cardiac dullness to percussion. The chest radiograph typically shows a large globular heart and clear lung fields. Echocardiography is the investigation of choice for confirming the presence of effusion and for assessing its volume.

Pericardial tamponade

Pericardial tamponade is a condition of haemodynamic instability caused by chamber compression because increased intrapericardial pressure is greater than the filling pressure of the right and left ventricles.

Presentation is typically with shortness of breath or circulatory collapse. The key physical findings are tachycardia, pulsus paradoxus (an exaggeration of the normal fall in systolic blood pressure on inspiration) of greater than 10 mmHg, and elevation of the venous pressure. Echocardiography is the most important investigation, providing clear evidence of fluid collection around the heart and presence of diastolic right ventricular or right atrial collapse. Immediate management is by pericardial aspiration.

Pericardial constriction

A stiff pericardium loses its stretching ability to accommodate normal changes in intracardiac pressures. Most patients present with leg or abdominal swelling and dyspnoea. The key physical findings are elevated venous pressure (with a characteristic ‘M’ or ‘W’ waveform), a pericardial knock, hepatomegaly, ascites, and oedema.

Investigation and diagnosis—Doppler echocardiography is the best noninvasive investigation. Cardiac catheterization demonstrates a difference of less than 5 mmHg between end-diastolic pressures in the two ventricles, persisting with respiration and fluid loading; a peak right ventricular pressure of less than 50 mmHg; and a ratio of end-diastolic to peak right ventricular pressure of more than 0.33.

Management—fluid retention in early pericardial constriction can be managed by diuretics, with pericardiectomy recommended for patients who are resistant.

Chapter.  5375 words.  Illustrated.

Subjects: Cardiovascular Medicine

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