Pericardial Disease (Pericarditis and Pericardial Tamponade)

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Chapter 31 Pericardial Disease (Pericarditis and Pericardial Tamponade)

Stuart F. Sidlow, MD , C. William Hanson, III , MD

1 What is the structure of the pericardium?

The pericardium is a two-layered structure surrounding the heart and consisting of the fibrous and serous layers. The fibrous layer is a stiff, inelastic structure, which has little ability to accommodate fluid accumulation over a short time course. The serous layer consists of two layers, the parietal and visceral pericardium. The parietal layer is adherent to the fibrous pericardium, and the visceral layer is part of the epicardium or external layer of the heart wall. When pericardial effusion occurs, it normally is between the parietal and visceral layers of the serous pericardium. The pericardial space normally holds 15 to 50 mL of an ultrafiltrate of plasma.

2 Why do hemodynamic changes occur with the buildup of fluid between the layers of the serous pericardium?

When fluid accumulates in the pericardial space, the fibrous pericardium has little ability to stretch. As the volume increases in this space, further inflow into the right side of the heart is impaired, which results in decrease in filling of the left side of the heart, and thus preload is decreased.

3 What general types of pericardial disease exist?

Acute fibrinous pericarditis (acute pericarditis)

Pericardial effusion without hemodynamic compromise

Cardiac tamponade

Constrictive pericarditis

5 Describe the clinical manifestation of acute pericarditis (history and physical examination)

Patient may complain of pleuritic chest pain worse on inspiration. Pain is exacerbated by supine position and relieved by sitting up. Dyspnea may be present. A pericardial friction rub is highly specific to acute pericarditis. Many are seen initially with high fever (temperature > 38° C) and new cardiomegaly on chest radiograph. Pleural effusions are frequently observed.

6 What is on the differential diagnosis of acute pericarditis?

Differential diagnosis of acute pericarditis consists of acute myocardial infarction, pulmonary embolus, gastroesophageal reflux, and musculoskeletal pain.

7 How is acute pericarditis manifested on electrocardiography (ECG)?

There is a progression of four stages on ECG, but for diagnosis one should evaluate for concave-up ST segments throughout most leads (exceptions include aV_R and V₁).

8 What other diagnostic tests are useful in diagnosis of acute pericarditis?

Serum cardiac troponin I and creatine kinase, myocardial bound (CKMB) levels should be evaluated. Usually mild troponin increases occur in the absence of increased CKMB levels. The increase is due to inflammation of myocardium. Other tests may include (on the basis of suspicion and other findings) antinuclear antibodies, tuberculin skin test, human immunodeficiency virus serology, and blood cultures.

9 How is pericardiocentesis used in diagnosing or treating acute pericarditis?

Pericardiocentesis or surgical drainage should be performed for one of three reasons:

If moderate to severe tamponade is present, resulting in hemodynamic compromise (class I recommendation)

If purulent, TB or neoplastic effusion is suspected (class IIa recommendation)

If a persistently symptomatic effusion is present

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