Pericardial rub

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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33 Pericardial rub

Instruction

Listen to this patient’s heart.

Salient features

History

• Precordial pain changing with posture (worse on lying down and relieved by sitting forward)

• Myocardial infarction

• Viral infection (coxsackie A and B viruses)

• Chronic renal failure

Examination

• Scratching and grating sound heard best with the diaphragm at the left sternal border, with the patient leaning forward and the breath held in expiration.

Note: A pericardial rub does not occur in acute pericarditis and it is common for the rub to disappear when a pericardial effusion develops.

• Tell the examiner that you would like to do an ECG (Fig. 33.1), see a chest radiography (Fig. 33.2) and echocardiogram (Fig. 33.3).

Fig. 33.1 Pericarditis with sinus tachycardia, diffuse, concave upward ST segment elevation, PR segment depression (lead II) and PR segment elevation (lead aVR).

Fig. 33.2 Chest radiograph in acute non-specific pericarditis, showing cardiopericardial shadow caused by pericardial effusion.

(With permission from Kliegman et al. 2007.)

Fig. 33.3 Echocardiographic images of large pericardial effusion (PE) with features of tamponade. (A) Apical four-chamber view showing large PE with diastolic right-atrial collapse (arrow). (B) M-mode image in parasternal long axis showing circumferential PE with diastolic collapse of RV free wall (arrow) during expiration. (C) M-mode image from subcostal window showing IVC plethora without inspiratory collapse.

(With permission from Troughton et al. 2004.)

Diagnosis

This patient has a pericardial rub (lesion) caused by pericarditis secondary to uraemia (aetiology) and is not in pain (functional status).

Questions

What are the characteristic features of a pericardial friction rub?

It typically consists of three components:

• A presystolic rub during atrial contraction

• A ventricular systolic rub, which is almost always present and usually the loudest component

• A diastolic rub, which follows the second heart sound (during rapid ventricular filling).

Advanced-level questions

What are the characteristic electrocardiographic findings?

• ST elevation in most ECG leads with the concavity upwards.

• T wave inversion occurs after the ST segment returns to baseline (unlike in acute myocardial infarction where the ST segment is concave downwards like a cat’s back and there is some amount of T wave inversion accompanying the ST elevation).

• PR-segment depression (caused by inflammation of the atrial wall).

How common is pericardial rub in constrictive pericarditis?

It is not heard in constrictive pericarditis.

What is the treatment for acute pericarditis?

• Pain relief (codeine) and NSAIDs (e.g. indometacin)

• Steroids should be considered only when the pain does not respond to a combination of NSAIDs

• Treatment of the underlying cause

• Treatment of pain: colchicine has been used to treat recurrent pain of pericarditis; rarely pericardiectomy may be required for pain even in the setting of no haemodynamic impairment.

What do you know about transient constrictive phase of acute pericarditis?

About 10% of the patients with acute pericarditis have a transient constrictive phase, which may last 2 to 3 months before it gradually resolves either spontaneously or with treatment with anti-inflammatory drugs. These patients usually have a moderate amount of pericardial effusion and as the effusion resolves, the pericardium remains thickened, inflamed and non-compliant, resulting in constrictive haemodynamics. Clinical features include shortness of breath, raised JVP, peripheral oedema and ascites. Constrictive haemodynamics can be documented by Doppler echocardiography and resolution of constrictive physiology can be serially followed by this technique.

What are the indications for drainage of pericardial fluid?

• Overt clinical tamponade, in those with suspicion of purulent pericarditis and in patients with idiopathic chronic large pericardial effusion.

• Tamponade, either unresolved or relapsing after pericardiocentesis, and persistent active illness 3 weeks after hospital admission.

Note: Pericardial drainage is not indicated in the initial management of patients with large pericardial effusions without clinical tamponade because of its low diagnostic yield and poor influence on the evolution of pericardial effusion. Even the presence of right chamber collapse (suggesting raised intrapericardial pressure) on echocardiography does not by itself warrant pericardial drainage because most of these patients do not evolve to overt tamponade.

What is Dressler syndrome?

It is characterized by persistent pyrexia, pericarditis and pleurisy. It was first described in 1956 when Dressler recognized that postmyocardial infarction chest pain is not caused by coronary artery insufficiency. It usually occurs 2–3 weeks after myocardial infarction and is considered to be of autoimmune aetiology; it responds to NSAIDs.

What do you know about postcardiotomy syndrome?

It occurs in about 5% of patients who have cardiac surgery and with symptoms of pericarditis from 3 weeks to 6 months after surgery. It is initially treated with NSAIDs, and with systemic steroids if refractory. Pericardiectomy is rarely required. It is said to be the result of autoimmune response and is most likely to be related to surgical trauma and irritation of blood products in the mediastinum and pericardium.

What are the functions of pericardium?

• The pericardium protects and lubricates the heart.

• It contributes to the diastolic coupling of the LVs and RVs: an effect that is important in cardiac tamponade and constrictive pericarditis.

W Dressler (1890–1969), US physician educated in Vienna. He worked at the Manimoides Hospital, Brooklyn, New York.

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