Pericardial Disease

Pericardial Basics - Heart's Cozy Coat

• Layers & Space:
  • Outer: Tough Fibrous Pericardium.
  • Inner: Serous Pericardium:
    • Parietal layer (lines fibrous).
    • Visceral layer (epicardium; on heart surface).
  • Pericardial Cavity: Space between serous layers; contains 15-50 mL of lubricating fluid.
• Core Functions:
  • Limits acute cardiac distension.
  • Reduces friction during cardiac motion.
  • Barrier against infection/inflammation.

⭐ The pericardium is composed of an outer fibrous layer and an inner serous layer (parietal and visceral, with the pericardial cavity between them).

Acute Pericarditis - Chest Pain Drama

• Etiology: Most common: Idiopathic, Viral (Coxsackie B). Others: Uremia, Post-MI (Dressler's syndrome), TB, Autoimmune (SLE), Neoplastic.
• Clinical: Sharp, pleuritic chest pain (relieved sitting up/leaning forward, worse supine). Fever. Pericardial friction rub (triphasic, transient).
• ECG: Diffuse concave ST elevation & PR depression. Stages:
  • I: Widespread ST↑, PR↓
  • II: ST/PR normalize
  • III: T-wave inversions
  • IV: ECG normalizes
• Diagnosis: Requires ≥2 of 4 criteria:
  • Typical pericarditic chest pain
  • Pericardial friction rub
  • Characteristic ECG changes (new ST↑ or PR↓)
  • New or worsening pericardial effusion

⭐ The most common causes of acute pericarditis are idiopathic and viral infections.

• Management: NSAIDs (e.g., ibuprofen) + Colchicine (reduces recurrence). Corticosteroids for refractory cases or specific indications (e.g., autoimmune, uremic if NSAIDs fail/contraindicated).

Effusion & Tamponade - Squeezing The Pump

• Pericardial Effusion: Fluid >50mL in pericardial space.
• Cardiac Tamponade: Effusion causing hemodynamic compromise.
  • Pathophysiology: ↑ Intrapericardial pressure → ↓ Venous return → ↓ Diastolic filling → ↓ Stroke volume → Hypotension, shock.
  • Clinical (Tamponade):
    • Beck's Triad: Hypotension, ↑JVP (Distended Neck Veins), Muffled heart sounds. 📌 3 D's: Decreased Arterial Pressure, Distended Jugular Veins, Distant Heart Sounds.
    • Pulsus Paradoxus: >10 mmHg SBP fall on inspiration.
    • Tachycardia, dyspnea.
  • Diagnosis:
    • Echocardiography (key): Effusion size, diastolic RV/RA collapse, swinging heart.
    • ECG: Low voltage QRS, electrical alternans.
  • Management:
    • Urgent Pericardiocentesis: Diagnostic & therapeutic for tamponade.
    • IV fluids (temporizing).
    • Treat underlying cause.

⭐ Electrical alternans on ECG is highly suggestive of large pericardial effusion and cardiac tamponade.

Constrictive Pericarditis - Heart In A Vise

Thickened, fibrotic, often calcified pericardium restricts diastolic filling.

• Etiology: Idiopathic, post-surgery, radiation, TB, recurrent pericarditis.
• Pathophysiology: Impaired ventricular filling → equalization of diastolic pressures.
• Clinical: RHF (edema, ascites), dyspnea.
  • Pericardial knock (early diastolic).
  • Kussmaul's sign (paradoxical ↑JVP on inspiration).
  • Friedreich's sign (rapid y-descent JVP).
• Diagnosis:
  • Echo: Septal bounce, respiratory variation in inflow.
  • CT/MRI: Pericardial thickening >4mm, calcification.
  • Cath: Dip-and-plateau (square root sign).

⭐ Kussmaul's sign, a paradoxical rise in jugular venous pressure during inspiration, is a characteristic finding in constrictive pericarditis.

• Management: Pericardiectomy.

CP vs. Restrictive Cardiomyopathy (RCM)

High‑Yield Points - ⚡ Biggest Takeaways

• Fibrinous pericarditis: most common, post-MI (Dressler's syndrome), uremia; key sign is friction rub.
• Constrictive pericarditis: impaired diastolic filling; look for Kussmaul's sign, pericardial knock.
• Cardiac tamponade: Beck's triad (hypotension, JVD, muffled sounds) and pulsus paradoxus are classic.
• Acute pericarditis: commonly viral (Coxsackie B); causes sharp chest pain, diffuse ST elevation.
• Tuberculous pericarditis: a major cause of chronic constrictive pericarditis in endemic areas.
• Uremia and malignancy are important non-infectious causes of pericarditis and large effusions respectively.