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Acute Pericarditis
Acute pericarditis is a syndrome reflecting inflammation of the pericardial space. Etiologies are multiple, including idiopathic, infection (viral), malignancies, uremia, anticoagulant therapy, dissecting aneurysm, collagen vascular disorders, trauma, radiation, drug therapy, and
While the presentation may be incidental - a serendipitous finding on evaluation of an EKG, Chest X Ray, or echo - most present as chest pain, a friction rub, or the low output state of tamponade. The chest pain is distinctive for its precordial, parasternal location, radiation to the left shoulder and arm, and positional character (worse on lying down than when up). The auscultation of the rub is notable for location at the left sternal border, 1-3 components. If tamponade is evident, a Kussmaurs sign (inspiratory rise of jugular pressure is evident as is
EKG changes with pericarditis may be found in up to 50-70% of cases. The principal rhythm is sinus. Imaging of the pericardium is most easily accomplished with transthoracic echocardiogram. MRI and CT remain the most definitive modalities. Chest X Rays may only show changes after several hundred ccs of fluid have accumulated, but are mandatory to evaluate pulmonary parenchyma and vessels.
The clinical strategy for acute pericarditis is to identify an underlying cause, particularly iatrogenic procedures, drugs, infections, and neoplasm. Physiological consequences should be assessed - rule out tamponade. Pericardiocentesis is warranted in the setting of tamponade, suspected bacterial or mycobacteria! infection, recurrent effusions, or
Therapy for pericarditis is directed to specific etiologies if they have been identified. Non specific therapies include anti inflammatory therapy. Non steroidals, including ASA, should be employed first once infection has been excluded. Steroids are invariably useful but should be reserved for failure of non steroidals given the risks of long term therapy. Analgesics are usually need in conjunction with anti inflammatory medication. Response to therapy is marked by resolution of pain and inflammation. If an effusion is measurable, it should be shown to resolve by echo.
Tamponade
Pericardial tamponade is a state of increased intrapericardial pressure due to accumulation of fluid which leads to increased venous pressure, impaired ventricular filling, reduced cardiac output, and falling blooc pressure. It may be due to any etiology of acute or chronic pericarditis that leads to accumulation of fluid. The clinical hallmarks are always those of elevated venous pressure and paradoxical pulse. Less ofen, does one find shock, muffled heart tones, friction rub. The diagnosis is a clinical one. Transthoracic echocardiography is a useful adjunct when it shows findings of right atrial diastolic collapse, right ventricular diastolic collapse, and left atrial collapse. Right heart catheterization can make a definitive diagnosis, but may be misleading in case., of
Management of pericardial tamponade requires pericardiocentesis. In hemodynamic emergencies, this can be performed at the bedside with EKG guidance. In urgent circumstances, when the patient can be stabilized, the individual should be taken to a cath lab for pericardiocentesis. Fluid is sent for cell counts, gram stain, cytology, and serological studies. Recurrent tamponade may be handled with recurrent pericardiocentesis, catheter periocardiotomy, or surgical "windows." Once stabilized, the patient can be treated for the underlying condition. Major errors in the management of patients include using diuretics and nitrates for chest pain, failure to identify underlying treatable conditions, and over reliance on the echo for
Constrictive Pericarditis
This uncommon disorder is due to fibrous thickening of the pericardium due to subacute or chronic inflammation leading to elevated systemic and pulmonary pressures with symptoms of dyspnea, fatigue, dependent edema, and ascites. Most cases are idiopathic, but definable etiologies include irradiation, post pericarditis, post surgical, neoplastic, and connective tissue disease. Differential diagnosis excludes restrictive cardiomyopathy. Evaluation requires imaging of pericardium - thickening is a hallmark. Management necessitates surgical removal of the pericardium.