PERICARDITIS AND

PERICARDIAL
EFFUSION

Pericarditis and
Pericardial effusion
The pericardium forms a strong
protective sac around the heart. It is
composed of an outer fibrous and an
inner serosal layer with approximately
50 ml of pericardial fluid between
these in the healthy state.

Acute pericarditis
Acut epericarditis is caused by
iflammation of the pericardium

Clinic features
History
The chest pain of acute pericarditis is
usually central or left sided pain that is
sharp in nature and relieved by sitting
forwards. Aggraating factors include lying
supine and coughing.
Dyspnoea may be caused by the pain of
deep inspiration or the haemodynamic
effects of an associated pericardial effusion.

On examination
The patient may have a fever &
tachycardia.
a pericardial friction rub may be
heard on auscultation of the heart. This
is a high pitched scratching sound
( therefore heard best with the
diaphragm ). It characteristically varies
with time & may appear & disappear
from one examination to the next. It
sounds closer to the ears than a murmur.

Investigation
Blood tests
These will provide evidence of active
inflammation raised white cells count,
erythrocyte sedimentation rate ( ESR ), and
C-reactive protein ( CRP ), and also clues
about the underlying cause, the following
blood tests are appropriate :
Full blood count
ESR and CRP
Urea, creatinine, and electrolytes

 Viral titres in the acute and

convalescent phase ( 3 weeks later ),
also urine and faecal samples for viral
studies and a Paul Brunnel test
Blood cultures ( at least three )
Autoantibody titres ( antinuclear
antibodies, rheumatoid factor )
Cardiac enzymes and troponin T /
troponin I these may be elevated,
suggesting that the inflammatory
process involves the myocardium
( myopericarditis )

Electrocardiography
Superficial myocardial injury caused by
pericarditis results in characteristic ECG
changes

Concave ST segment elevation is usually

present in all leads except AVR and VI

Subsequently a few days later the ST

segments return to normal and T wave
flattening occurs and may even become
inverted

Finally all of the changes resolve and the

ECG
trace returns to normal ( this may
take several
weeks or if the inflammation
persists may remain for many months )

Chest radiography
This is normal in most cases of ucomplicated
acute pericarditis, however, a number of
changes are possible :
A pericardial effusion may develop and if
large will result in enlargement of the cardiac
shadow, which assumes a globular shape

Pleural effusions may also be seen

Echocardiography
This is the best investigation for confirming
the presence of a pericardial effusion. In
uncomplicated acute pericarditis, however,
the echocardiogram may be normal

Causes of acute pericarditis

Cause

Examples / Comment

Viral infection

Coxsackie virus A & B, echovirus, epstein-Barr virus, HIV

Bacterial infection Pneumococci, staphylococci, Gram negative organisms, Neisseria

meningitidis, N gonorrhoeae
Other infection

Histoplasmosis, candidal infection

Acute MI

Occurs in up to 25% of patients between 12 h and 6 days after

infarction

uraemia

Usually a haemorrhage pericarditis, which can rapidly lead to cardiac

tamponade; uraemic pericarditis is an indication for haemodialysis

Autoimmune
disease

Acute rheumatic fever, SLE, rheumatoid arthritis, scleroderma

Other causes

Neoplastic disease, other imlammatory diseases : sarcidosis,

whipples disease, Behcets syndrome, Dresslers syndrome
( postcardiotomy syndrome )

Management
Any treatable underlying cause should of
course be sought and treated appropriately. Most
cases of pericarditis are viral or idiopathic. The
main aims of management are therefore
analgesia and bed rest. Non steroidal anti
inflammatory agents are most effective for this
condition. Occasionally a short course of oral
corticosteroids is required.
A pericardial effusion may be present. If large
of causeing tamponade this can be drained.
Analysis of the effusion may provide clues about
the underlying cause of the pericarditis

Dresslers syndrome
Dressiers syndrome is a syndrome of fever,
periarditis and pleurisy occuring more than 1
week after a cardiac operation or myocardial
infarction ( MI ). It can occur only if the
pericardium has been exposed to the blood.
Antibodies from against th epericardial
antigens and then attaack the pericardium in
a type III autoimmune reaction.
patients present with fever, malaise and
chest pain. They exhibit the classic signs
acute pericarditis ; they may also have
athritis.
Cardiac
tamponade
is
not
uncommon.

Chest radiography shows pleural

effusions.
Echocardiography
may
reveal a pericardial effusion.
Initial management consists of non
steroidal antiinflammatory agents and
aspirin ; corticosteroids may be added
if the symptoms persist

Chronic contrictive
pericarditis
Chronic contrictive pericarditis occurs
when
the
pericadium
becomes
fibrosed and thickened and eventually
restricts the filling of the heart during
diastole.

Clinical features
The restricted filling of all four chambers
of the heart results in low output failure
Initially the right sided component is
more marked, resulting in a high venous
pressure and hepatic congestion.
Later left ventricular failure becomes
apprent with dyspnoea and orthopnoea

On examination
On examination the signs of right and left
ventricular failure are evident but the ventricles are
not enlarged.
The single most important feature in the
examination of such a patient is the jugular venous
pressure ( JVP ), which is elevated. Kussmauls sign
an increase in the JVP during inspiration may be
evident.
Another important feature of the JVP is a rapid x
and y descent. This is an important differential
diagnostic point when trying to exclude tamponade.
There is no such feature is tamponade.
The heart sounds are often soft. Atrial
fibrillation is common

Causes of chronic contrictive pericarditis

Viral infection
Tuberculosis
Mediastinal radiotherapy
Mediastinal malignancy
Autoimmune disease

Investigation
Blood rests are carried out to exclude a
possible underlying cause ( leucocytosis
in infection, viral titres )
On chest radiography the heart size
is normal there may be signs of a
neoplasm of tuberculosis. Pleural
effusions are not uncommon.
Tubercolous pericarditis may be
associated with radiograpically visible
calcification.

Echocardiography shows good left

ventricular function
Cardiac
catheterization
is
diagnostic because it shows the
classical pattern of raised left and
right end diastolic pressures with
normal left ventricular function on the
ventriculogram.

Management
The
only
definitive
treatment
pericardectomy.
antitubercolous therapy may
required if the underlying cause
tubercolosis and should be continued
1 year

is
be
is
for

Pericardial effusion
A
pericardial
effusion
is
an
accumulation of fluid in the pericardial
space.
cardiac tamponade describes the
condition where a pericardial effusion
increases the intrapericardial pressure.

Causes
Causes of pericardial effusion
include :
Acute pericarditis
MI with ventricualr wall rupture
Chest trauma
Cardiac surgery
Aortic dissection

Causes of a pericardial effusion

Type of effusion

example

Trabscudate
( < 30 g/L protein )

Congestive cardiac failure, hypoalbuminaemia

Exudate
( > 30 g/L protein )

Infection ( viral, bacterial or fungal ), postmyocardial

infarction, malignancy ( local infasion of lung
tumour), systemic lupus erythematosus, Dresslers
syndrome

Haemorrhage

Uraemia, aortic dissection, trauma and postcardiac

surgery

Clinical features
A pericardial effusions may remain
asymptomatic even is large if it
avvumulates gradually. As much as 2 L
of fluid can be accommodated without
an
increase
in
intrapericardial
pressure if it accumulates slowly, but
as little as 100 ml can cause
tamponade if it apperas suddenly.

History
The only symptoms produced by a large
chronic effusion may be a dull ache in
the
chest
or
dysphagia
from
compression of the oesophagus.
if cardiac tamponade is present,
however, the patient may complain of
dyspnoea, abdominal swelling ( due to
ascites ) and peripheral oedema

Examination
The important examination findings in a
Patient who has tamponade are :
Low blood pressure
Pulse low volume, and may be pulsus
paradoxus ( where there is an
exaggerated reduction of the pulse >
10 mmHg during inspirarion )
Soft heart sounds

Possible mechanisms for

pulsus paradoxus
These are :
Increased
venous
return
during
inspiration filling the right heart and
restricting
left
ventricular
filling
because the pericardium forms a rigid
sac with only limited space within it
Downward
movement
of
the
diaphragm causing raction on the
pericardium and tightening it further
( this theory is not widely supported )

Investigation
Electrocardiography
A pericardial effusion results in the production
of small voltage complexes with variable axis
( electrical alternans is caused by the
movement of the heart within the fluid )
On chest radiography the heart may appear
large and gobular
Echocardiographyreveals the pericardial
effusion right ventricular diastolic collapse is a
classical echocardiography sign of tamponade.

Management
The pericardial effusion should be
drained.
If
the
patient
is
in
cardiogenic shock due to tamponade
an emergency pericardial needle
aspiration may be performed followed
by formal drainage once the patient
has been resuscitated.

Both techniques involve insertion

of the drain or needle just below
xiphis ternum and advancing it at 45
degrees to the skin in the direction of
the patients left shoulder. The fluid
should
be
sent
for
cytology,
microscopy, culture and biochemical
analysis of protein content.
Long term treatment depends on
the underlying cause.