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PericardialPericardial
DiseasesDiseases
David Stultz, MD, FACCDavid Stultz, MD, FACC
July 19, 2011July 19, 2011
www.drstultz.com
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Goals of ConferenceGoals of Conference
Identify signs and symptoms ofIdentify signs and symptoms of
pericardial diseasespericardial diseasesDiscuss workup and treatmentDiscuss workup and treatment
strategies for pericarditisstrategies for pericarditis List common causes of pericarditisList common causes of pericarditis
and pericardial effusionand pericardial effusion
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The PericardiumThe Pericardium
Outer fibrous layerOuter fibrous layer
Inner lining (serous)Inner lining (serous) Visceral pericardiumVisceral pericardium(epicardium)(epicardium)
Parietal pericardiumParietal pericardium
lines outer fibrouslines outer fibrouslayerlayer
Pericardial space isPericardial space isin between visceralin between visceraland parietaland parietalpericardiumpericardium Normally 15Normally 15--50mL of50mL of
fluidfluid
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Case #1Case #1
32 year old Male32 year old Male
1 week ago started with sore throat,1 week ago started with sore throat,myalgiasmyalgias
Developed chest pain (pressure)Developed chest pain (pressure) Left substernalLeft substernal
Radiating to neckRadiating to neck
Improves when sitting upImproves when sitting up
No significant medical, family, socialNo significant medical, family, social
historyhistory No medicationsNo medications
Physical Exam unremarkablePhysical Exam unremarkable
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Case #1 EKGCase #1 EKG
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Laboratory DataLaboratory Data
WBC 12.8WBC 12.8
Renal panel normalRenal panel normal
LDL 113LDL 113
Troponin I 4.0Troponin I 4.0CPK 240, CKCPK 240, CK--MB 21.8 (index 9.1%)MB 21.8 (index 9.1%)
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What is the most likely diagnosis?What is the most likely diagnosis?
1.1. Acute myocardial infarctionAcute myocardial infarction
2.2. Acute pericarditisAcute pericarditis3.3. Acute myopericarditisAcute myopericarditis
4.4. Constrictive pericarditisConstrictive pericarditis5.5. Pericardial tamponadePericardial tamponade
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What would you do next?What would you do next?
1.1. Cardiac CatheterizationCardiac Catheterization
2.2. EchocardiographyEchocardiographyOr go straight to treatment withoutOr go straight to treatment without
imaging:imaging:3.3. High dose NSAIDSHigh dose NSAIDS
4.4. High dose NSAIDS + ColchicineHigh dose NSAIDS + Colchicine5.5. PrednisonePrednisone
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Now What Would You Do ForNow What Would You Do For
Treatment?Treatment?1.1. Indomethacin 25mg po q6Indomethacin 25mg po q6--8h8h
2.2. Ibuprofen 800mg po q6hIbuprofen 800mg po q6h3.3. Aspirin 650Aspirin 650--800mg po q6800mg po q6--8h8h
4.4. Indomethacin + colchicine 0.6mg dailyIndomethacin + colchicine 0.6mg daily
5.5. Ibuprofen + colchicine 0.6mg dailyIbuprofen + colchicine 0.6mg daily
6.6. Aspirin + colchicine 0.6mg dailyAspirin + colchicine 0.6mg daily
7.7. Prednisone 60mg po daily with taperPrednisone 60mg po daily with taper
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What is the Most Common CauseWhat is the Most Common Cause
of Acute Pericarditis?of Acute Pericarditis?1.1. Idiopathic/ViralIdiopathic/Viral
2.2. BacterialBacterial3.3. MalignancyMalignancy
4.4. UremiaUremia5.5. Acute Myocardial InfarctionAcute Myocardial Infarction
6.6. Autoimmune diseaseAutoimmune disease
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Acute PericarditisAcute Pericarditis
Inflammation of PericardiumInflammation of Pericardium
Symptoms include sharp chest painSymptoms include sharp chest painOften improved with uprightOften improved with upright
positionposition
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Common Causes of AcuteCommon Causes of Acute
PericarditisPericarditis Idiopathic (85Idiopathic (85--90%)90%)
InfectiousInfectious
Viral (1Viral (1--2%)2%) Bacterial (1Bacterial (1--2%)2%)
Tuberculous (4%)Tuberculous (4%)
Neoplastic disease (7%)Neoplastic disease (7%)
UremiaUremia Before dialysis (5%)Before dialysis (5%)
After initiation of dialysis (13%)After initiation of dialysis (13%)
Systemic autoimmune disease (3Systemic autoimmune disease (3--5%)5%)
As a complication ofAs a complication of Acute myocardial infarction (5Acute myocardial infarction (5--20%)20%)
Myocarditis (30%)Myocarditis (30%)
Adapted from Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis
and management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Rare Causes of Acute PericarditisRare Causes of Acute Pericarditis
After cardiotomy or thoracic surgeryAfter cardiotomy or thoracic surgery
Aortic dissectionAortic dissectionChest wall traumaChest wall trauma
Chest wall irradiationChest wall irradiationAdverse drug reactionAdverse drug reaction
Rare Infectious causesRare Infectious causes FungalFungal
ParasitesParasites
Adapted from Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis
and management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Pericarditis Chest PainPericarditis Chest Pain
Sudden onsetSudden onset
RetrosternalRetrosternal Pleuritic/SharpPleuritic/Sharp
Worse with inspirationWorse with inspiration Improved when sitting up or leaningImproved when sitting up or leaning
forwardforwardChest pain can radiateChest pain can radiate
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Pericarditis Friction RubPericarditis Friction Rub
Caused by rubbing of inflamed visceral andCaused by rubbing of inflamed visceral andparietal pericardiumparietal pericardium
Variable over timeVariable over time
Present in 85% of patients with pericarditis atPresent in 85% of patients with pericarditis atsome pointsome point
High pitched scratch or squeak at left lowerHigh pitched scratch or squeak at left lowersternal bordersternal border
Classically 3 phasesClassically 3 phases
Atrial systole,Atrial systole, Ventricular systoleVentricular systole
Rapid ventricular filling during early diastoleRapid ventricular filling during early diastole
May be only biphasic or monophasicMay be only biphasic or monophasicKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
http://depts.washington.edu/physdx/heart/tech5.html
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Pericarditis EKG ChangesPericarditis EKG Changes
Diffuse ST segment elevation and PR segmentDiffuse ST segment elevation and PR segmentdepressiondepression
Stage 1Stage 1 Hours to daysHours to days
ST elevation and PR depressionST elevation and PR depression
Possible PR segment elevation in aVRPossible PR segment elevation in aVR
Stage 2Stage 2 Normalization of ST and PR segmentsNormalization of ST and PR segments
Stage 3Stage 3
Diffuse T wave inversionsDiffuse T wave inversions
Stage 4Stage 4 EKG normalizes (or T wave inversions persist)EKG normalizes (or T wave inversions persist)
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Laboratory Studies in PericarditisLaboratory Studies in Pericarditis
Nonspecific elevation of inflammatory markersNonspecific elevation of inflammatory markers Erythrocyte sedimentation rateErythrocyte sedimentation rate
CC--reactive proteinreactive protein White blood cell countWhite blood cell count
Viral titers and cultures not usefulViral titers and cultures not useful
ANA, Rheumatoid factor useful only if otherANA, Rheumatoid factor useful only if otherautoimmune findings are presentautoimmune findings are present
Elevated troponinElevated troponin
Mild increase when presentMild increase when present Usually patent coronary arteries at catheterizationUsually patent coronary arteries at catheterization
Usually resolve in 1Usually resolve in 1--2 weeks2 weeks
Prognosis is goodPrognosis is good
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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MyopericarditisMyopericarditis
Predominantly pericardial involvementPredominantly pericardial involvementwith associated myocardialwith associated myocardialinflammation.inflammation.
Diagnosed after pericarditis diagnosedDiagnosed after pericarditis diagnosed
and evidence of myocardial involvementand evidence of myocardial involvement Abnormal cardiac enzymesAbnormal cardiac enzymes
New onset of global or regional leftNew onset of global or regional leftventricular dysfunctionventricular dysfunction
Endomyocardial biopsy not neededEndomyocardial biopsy not needed
Approximately 17% of patientsApproximately 17% of patients
ultimately diagnosed with pericarditisultimately diagnosed with pericarditisundergo heart catheterizationundergo heart catheterizationSalisbury AC, Olalla-Gomez C, Rihal CS, et al. Frequency and predictors of urgent coronary angiography in patients with acute
pericarditis. Mayo Clin Proc. 2009;84(1):11-15.
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Imaging StudiesImaging Studies
Chest XChest X--rayray Usually not helpful unlessUsually not helpful unless
there is a significant pericardial effusionthere is a significant pericardial effusion EchocardiographyEchocardiography Indicated forIndicated for
hemodynamic compromisehemodynamic compromise
Computed TomographyComputed Tomography useful touseful tomeasure pericardial thickness (usually 1measure pericardial thickness (usually 1--
2mm) and pericardial effusion2mm) and pericardial effusion
Cardiac MRICardiac MRI Delayed gadoliniumDelayed gadolinium
enhancement shows inflammation ofenhancement shows inflammation of
pericarditispericarditisKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Cardiac MRI of PericarditisCardiac MRI of Pericarditis
Delayed Gadolinium EnhancementDelayed Gadolinium Enhancement
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Initial EvaluationInitial Evaluation
HistoryHistory
Any suggestion of malignancy orAny suggestion of malignancy orautoimmune diseaseautoimmune disease
Physical ExaminationPhysical Examination
Friction rubFriction rub
Signs of TamponadeSigns of Tamponade
Pulsus ParadoxusPulsus ParadoxusKussmaulKussmauls signs sign
BeckBecks Triads Triad
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Selected EvaluationsSelected Evaluations
Echocardiogram for hemodynamicEchocardiogram for hemodynamiccompromisecompromise
Suspected autoimmune diseaseSuspected autoimmune disease Antinuclear Antibody titersAntinuclear Antibody titers
Rheumatoid FactorRheumatoid Factor Suspected infectious diseaseSuspected infectious disease
Tuberculin skin testingTuberculin skin testing
Human Immunodeficiency VirusHuman Immunodeficiency Virus Blood CulturesBlood Cultures
Malignancy workupMalignancy workup
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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HospitalizationHospitalization
Any high risk featuresAny high risk features FeverFever
LeukocytosisLeukocytosis
Large pericardial effusion (>20 mm)Large pericardial effusion (>20 mm)
Cardiac tamponadeCardiac tamponade
Acute traumaAcute trauma
Immunosuppressed stateImmunosuppressed state
Anticoagulated patientAnticoagulated patient
Failure of NSAID treatmentFailure of NSAID treatment
Abnormal troponinAbnormal troponin
Recurrent pericarditis.Recurrent pericarditis.
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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OutpatientOutpatient Day HospitalDay Hospital ManagementManagement
No high risk featuresNo high risk features
254 out of 300 cases low risk254 out of 300 cases low risk Treated with Aspirin 800mg q6Treated with Aspirin 800mg q6--8h x 28h x 2--3 weeks with3 weeks with
taperingtapering
Baseline echocardiogramBaseline echocardiogram
Clinical and echo followClinical and echo follow--up periodically over 1 yearup periodically over 1 year
Mean followMean follow--up of 38 monthsup of 38 months 43 (16.9%) cases of relapses43 (16.9%) cases of relapses
4 (1.6%) cases of constrictive pericarditis4 (1.6%) cases of constrictive pericarditis
No cases of cardiac tamponadeNo cases of cardiac tamponade
Failure to respond to Aspirin after 7Failure to respond to Aspirin after 7--10 days10 dayspredicted higher rates of complicationpredicted higher rates of complication
Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J
Am Coll Cardiol. 2004;43(6):1042-1046.
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Treatment of PericarditisTreatment of Pericarditis NSAIDSNSAIDS
High dose Aspirin or ibuprofenHigh dose Aspirin or ibuprofen Aspirin 800mg q6Aspirin 800mg q6--8h x 78h x 7--10 days then taper off over 210 days then taper off over 2--3 weeks3 weeks
GI prophylaxis recommendedGI prophylaxis recommended
Indomethacin not recommended in patients with coronaryIndomethacin not recommended in patients with coronarydiseasedisease
ColchicineColchicine Use in conjunction with aspirin for 4Use in conjunction with aspirin for 4--6 weeks6 weeks
Caution with severe renal insufficiency, hepatobiliaryCaution with severe renal insufficiency, hepatobiliarydysfunction, gastrointestinal motility disordersdysfunction, gastrointestinal motility disorders
CorticosteroidsCorticosteroids Reserved for patients failing initial therapy withReserved for patients failing initial therapy with
NSAID+colchicineNSAID+colchicine
Increased risk of relapsing pericarditisIncreased risk of relapsing pericarditis Consider using inConsider using in Autoimmune diseaseAutoimmune disease
Connective tissue disorderConnective tissue disorder
Uremic pericarditisUremic pericarditis
Prednisone 1mg/kg/day, taper after 2Prednisone 1mg/kg/day, taper after 2--4 weeks of therapy4 weeks of therapy
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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COPE TrialCOPE Trial
120 Patients with first episode120 Patients with first episodepericarditispericarditis
ConventionalConventional ASA 800mg q6ASA 800mg q6--8h for 78h for 7--10 days with tapering10 days with tapering
over 3over 3--4 weeks4 weeks
ExperimentalExperimental ASA + Colchicine 1ASA + Colchicine 1--2mg day 1 then 0.52mg day 1 then 0.5--1mg1mg
daily for 3 monthsdaily for 3 months
Addition of Colchicine beneficialAddition of Colchicine beneficial Lower rate of recurrence at 18 months (11%Lower rate of recurrence at 18 months (11%vs. 33%)vs. 33%)
Better 72 hour symptom resolution (12% vs.Better 72 hour symptom resolution (12% vs.
37%)37%)Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, TrincheroR. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial.Circulation. 2005 Sep 27;112(13):2012-6.
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Relapsing pericarditisRelapsing pericarditis
Usual first recurrence within 18 monthsUsual first recurrence within 18 months
IncessantIncessant Pericarditis returns within 6 weeks of treatmentPericarditis returns within 6 weeks of treatment
discontinuationdiscontinuation
IntermittentIntermittent
Usually responds to steroidsUsually responds to steroids Usual causesUsual causes
AutoimmuneAutoimmune
Viral or other infectionViral or other infection
PostPost--pericardial/Postpericardial/Post--myocardial injury syndromesmyocardial injury syndromes
Consider pericardiectomy in extreme casesConsider pericardiectomy in extreme cases
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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Case #1Case #1
Diagnosis: MyopericarditisDiagnosis: Myopericarditis
Treated with ibuprofen 800mg poTreated with ibuprofen 800mg poq8h x 5 days then 400mg po q12h xq8h x 5 days then 400mg po q12h x5 days5 days
Started on carvedilol 3.125mg poStarted on carvedilol 3.125mg poq12hq12h
Discharged after overnightDischarged after overnighthospitalizationhospitalization
Doing well at 3 month followDoing well at 3 month follow--upup
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Case #2Case #2
53 year old male53 year old male
Increasing chest pressure and neck painIncreasing chest pressure and neck pain Almost constantAlmost constant
Worse with activity or deep breathWorse with activity or deep breath
Better when sitting upBetter when sitting up
Fevers, chills, nausea, and vomiting 3 monthsFevers, chills, nausea, and vomiting 3 monthsagoago
Past medical historyPast medical history HypertensionHypertension
HyperlipidemiaHyperlipidemia
No pertinent medications, family or socialNo pertinent medications, family or socialhistoryhistory
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Case #2 EKGCase #2 EKG
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CAT Scan of the ChestCAT Scan of the Chest
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EchocardiogramEchocardiogram
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Cardiac TamponadeCardiac Tamponade
Increased fluid in pericardial spaceIncreased fluid in pericardial space
Increases intracardiac pressuresIncreases intracardiac pressures Impairs normal cardiac fillingImpairs normal cardiac filling
Exaggerated by respirationsExaggerated by respirations
Inspiration decreases right ventricularInspiration decreases right ventricular
pressure but increases left ventricularpressure but increases left ventricular
pressurepressure
May be acute, subacute, or chronicMay be acute, subacute, or chronic
Cardiac procedures are the most commonCardiac procedures are the most common
acute cause!acute cause!
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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DiagnosisDiagnosis
Symptoms may include chestSymptoms may include chest
discomfort, shortness of breathdiscomfort, shortness of breath Pulsus paradoxusPulsus paradoxus
Decrease in systolic blood pressure ofDecrease in systolic blood pressure of
>10mmHg with inspiration>10mmHg with inspiration
Jugular venous distensionJugular venous distension
Normal x descent (atrial diastole) withNormal x descent (atrial diastole) withblunted y descent (atrial systole)blunted y descent (atrial systole)
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
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Echocardiography in TamponadeEchocardiography in Tamponade
Right atrial collapse (late diastole)Right atrial collapse (late diastole)
Right ventricular collapse (earlyRight ventricular collapse (earlydiastole)diastole)
Respiratory variation ofRespiratory variation oftransvalvular inflow (i.e. the echotransvalvular inflow (i.e. the echo
pulsus paradoxus)pulsus paradoxus)
Tricuspid >40%Tricuspid >40%
Mitral >25%Mitral >25%
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Ri h A i l C llRi h A i l C ll
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Right Atrial CollapseRight Atrial Collapse
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Tricuspid Valve Inflow withTricuspid Valve Inflow with
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Tricuspid Valve Inflow withTricuspid Valve Inflow with
Respiratory VariationRespiratory Variation
2011 David Stultz
Mitral Valve Inflow withMitral Valve Inflow with
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Mitral Valve Inflow withMitral Valve Inflow with
Respiratory VariationRespiratory Variation
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Pericardial effusion withoutPericardial effusion without
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Pericardial effusion without
tamponadetamponade 1/3 of patients with large (>20mm)1/3 of patients with large (>20mm)
pericardial effusion develop tamponadepericardial effusion develop tamponade
Consider pericardiocentesis if effusion persistsConsider pericardiocentesis if effusion persists
more than 1 monthmore than 1 month
Regular clinical and echocardiographicRegular clinical and echocardiographicfollowfollow--up recommendedup recommended
Consider thoracic duct obstruction withConsider thoracic duct obstruction with
chylopericardium if persistentchylopericardium if persistent Consider hypothyroidismConsider hypothyroidism
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
P i di l H tPericardial Hematoma
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Pericardial HematomaPericardial Hematoma
Blood clot in pericardial spaceBlood clot in pericardial space
Causes tamponade physiologyCauses tamponade physiologyDiagnosed by transthoracic orDiagnosed by transthoracic or
transesophageal echocardiogramtransesophageal echocardiogram
EtiologyEtiology IatrogenicIatrogenic
post cardiac surgery or other procedurepost cardiac surgery or other procedure Aortic dissectionAortic dissection
TraumaTrauma
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2011 David Stultz
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What is the Most Common Cause ofWhat is the Most Common Cause of
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nonnon--Iatrogenic Cardiac Tamponade?Iatrogenic Cardiac Tamponade?1.1. Idiopathic/ViralIdiopathic/Viral
2.2. MalignancyMalignancy3.3. UremiaUremia
4.4. Acute Myocardial InfarctionAcute Myocardial Infarction5.5. Autoimmune diseaseAutoimmune disease
6.6. TraumaTrauma7.7. HypothyroidismHypothyroidism
2011 David Stultz
Case #3Case #3
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Case #3Case #3 50 year old female50 year old female Increasing dyspnea and orthopnea over several daysIncreasing dyspnea and orthopnea over several days
Bilateral lower extremity edema and night sweats for two daysBilateral lower extremity edema and night sweats for two days
Dry cough and lowDry cough and low--grade fever (101grade fever (101F) 10 days agoF) 10 days ago
Recent chest painsRecent chest pains Thoracentesis for bilateral pleural effusionsThoracentesis for bilateral pleural effusions
Recently diagnosed atrial fibrillation & atrial flutter on admisRecently diagnosed atrial fibrillation & atrial flutter on admissionsion
Past Medical HistoryPast Medical History HypothyroidismHypothyroidism
Hodgkin lymphoma (radiation & chemotherapy)Hodgkin lymphoma (radiation & chemotherapy) Basal cell carcinomaBasal cell carcinoma
MedicationsMedications Levothyroxine 112 mcg/day, diltiazem 30 mg q12h, propafanoneLevothyroxine 112 mcg/day, diltiazem 30 mg q12h, propafanone
150mg q12h, warfarin150mg q12h, warfarin
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Case #3Case #3
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Case #3Case #3
WBC 13.6, Hgb 12.3, Platelets 384WBC 13.6, Hgb 12.3, Platelets 384
Na 131, K+ 3.9, creatinine 1.0Na 131, K+ 3.9, creatinine 1.0 TSH 25.4, free T4 1.0TSH 25.4, free T4 1.0
Cholesterol 131, trigs 54, LDL 89, HDLCholesterol 131, trigs 54, LDL 89, HDL
3131
BNP 833BNP 833
Erythrocyte sedimentation rate 120Erythrocyte sedimentation rate 120 C Reactive protein 115C Reactive protein 115
INR 4INR 4
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2011 David Stultz
What is the Most LikelyWhat is the Most Likely
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Diagnosis?Diagnosis?1.1. HypothyroidismHypothyroidism
2.2. Acute pericarditisAcute pericarditis3.3. Pericardial tamponadePericardial tamponade
4.4. Restrictive cardiomyopathyRestrictive cardiomyopathy5.5. Constrictive pericarditisConstrictive pericarditis
6.6. Ischemic cardiomyopathyIschemic cardiomyopathy
2011 David Stultz
Constrictive PericarditisConstrictive Pericarditis
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Constrictive PericarditisConstrictive Pericarditis
Symptoms of heart failure withSymptoms of heart failure withpreserved ejection fractionpreserved ejection fraction
Due to thickening of pericardiumDue to thickening of pericardium Impairs diastolic fillingImpairs diastolic filling
Etiology in developed countriesEtiology in developed countries
IdiopathicIdiopathic Cardiac surgeryCardiac surgery
PericarditisPericarditis
Mediastinal radiation therapyMediastinal radiation therapy Tuberculosis is major cause inTuberculosis is major cause in
developing countriesdeveloping countries
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Constrictive Pericarditis vs.Constrictive Pericarditis vs.
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Restrictive CardiomyopathyRestrictive CardiomyopathyRestrictive Cardiomyopathy is RARERestrictive Cardiomyopathy is RARE
AmyloidosisAmyloidosis SarcoidosisSarcoidosis
Hypereosinophilic syndromesHypereosinophilic syndromes
Endomyocardial fibrosisEndomyocardial fibrosis
Chemotherapy or RadiationChemotherapy or Radiation
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Gross SpecimensGross Specimens
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Constrictive pericarditis vs.Constrictive pericarditis vs.Restrictive CardiomyopathyRestrictive Cardiomyopathy
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Diagnosis of ConstrictiveDiagnosis of Constrictive
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PericarditisPericarditisHistoryHistory
Physical examinationPhysical examination Jugular venous distentionJugular venous distention
KussmaulKussmauls sign (rise in JVD withs sign (rise in JVD with
inspiration)inspiration)
Pericardial knockPericardial knock
EKGEKG NonspecificNonspecific
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Chest XChest X--ray in Constrictive Pericarditisray in Constrictive Pericarditis
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Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Hemodynamics in a NutshellHemodynamics in a Nutshell
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Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy
In Constrictive Pericarditis there isIn Constrictive Pericarditis there is
ventricular interdependence accentuatedventricular interdependence accentuated
by respirationby respiration
As inspiration occurs, RV filling improves atAs inspiration occurs, RV filling improves at
the expense of LV fillingthe expense of LV filling
RV pressure increases as LV pressureRV pressure increases as LV pressure
decreasesdecreases
Echocardiographic criteria based on thisEchocardiographic criteria based on thisphenomenaphenomena
Can be measured invasivelyCan be measured invasively
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Hemodynamics in a NutshellHemodynamics in a Nutshell
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Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Treatment of ConstrictiveTreatment of Constrictive
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PericarditisPericarditis If transient due to acuteIf transient due to acute
inflammation, medical therapyinflammation, medical therapy If chronic, pericardiectomy isIf chronic, pericardiectomy is
consideredconsidered
Surgical mortality approaches 6%Surgical mortality approaches 6%
Must be a complete pericardiectomyMust be a complete pericardiectomy
Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
2011 David Stultz
Case #3 TreatmentCase #3 Treatment
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Case #3 TreatmentCase #3 eat e t
Started on furosemideStarted on furosemide
Levothyroxine dose increasedLevothyroxine dose increasedReferred to tertiary care center forReferred to tertiary care center for
pericardiectomypericardiectomy
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2011 David Stultz
Congenital Absence ofCongenital Absence of
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PericardiumPericardium Usually partial absence of leftUsually partial absence of left
pericardiumpericardium
Male predominanceMale predominance
Associated withAssociated with
Atrial septal defectAtrial septal defect Bicuspid aortic valveBicuspid aortic valve
Bronchogenic cystsBronchogenic cysts
Usually asymptomaticUsually asymptomatic
May require surgical closure of partialMay require surgical closure of partial
defect if symptomaticdefect if symptomaticKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and
management. Mayo Clin Proc. 2010 Jun;85(6):572-93.
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2011 David Stultz
2011 David Stultz
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http://radiopaedia.org/encyclopaedia/quizzes/all/11753
http://www.ctsnet.org/sections/clinicalresources/clinicalcases/article-16.html
2011 David Stultz
ConclusionsConclusions
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Acute pericarditisAcute pericarditis
Most often viralMost often viral
Treat with high dose NSAIDS + colchicineTreat with high dose NSAIDS + colchicine
Pericardial tamponadePericardial tamponade
Often caused by malignancyOften caused by malignancy Volume support until pericardiocentesisVolume support until pericardiocentesis
Constrictive pericarditisConstrictive pericarditis
Suspect with diastolic heart failure symptoms,Suspect with diastolic heart failure symptoms,thickened pericardium, and history ofthickened pericardium, and history of
pericarditis or radiation exposurepericarditis or radiation exposure