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Toronto Notes 2019 Pericardial Disease
Treatment
• mild:frequentobservationwithserialechos,treatunderlyingcause,anti-inflammatoryagents • severe:treatasintamponade(seeCardiacTamponade)
Cardiac Tamponade
Etiology
• majorcomplicationofrapidlyaccumulatingpericardialeffusion
• cardiactamponadeisaclinicaldiagnosis
• anycauseofpericarditisbutespeciallytrauma,malignancy,uremia,proximalaorticdissectionwith
rupture
Pathophysiology
• highintra-pericardialpressure→decreasedvenousreturn→decreaseddiastolicventricularfilling→ decreased CO → hypotension and venous congestion
Signs and Symptoms
• tachypnea,dyspnea,shock,muffledheartsounds
• pulsusparadoxus(inspiratoryfallinsystolicBP>10mmHgduringquietbreathing) • JVP“x”descentonly,blunted“y”descent
• hepaticcongestion/peripheraledema
Investigations
• ECG:electricalalternans(pathognomonicvariationinRwaveamplitude),lowvoltage • echo:pericardialeffusion,compressionofcardiacchambers(RAandRV)indiastole
• cardiaccatheterization
Treatment
• pericardiocentesis: Echo-guided
• pericardiotomy
• avoiddiureticsandvasodilators(thesedecreasevenousreturntoalreadyunder-filledRV→decrease
LV preload → decrease CO) • IVfluidmayincreaseCO
• treatunderlyingcause
Constrictive Pericarditis
Etiology
• chronicpericarditisresultinginfibrosed,thickened,adherent,and/orcalcifiedpericardium
• any cause of acute pericarditis may result in chronic pericarditis
• major causes are idiopathic, post-infectious (viral, TB), radiation, post-cardiac surgery, uremia, MI,
collagen vascular disease
Signs and Symptoms
• dyspnea, fatigue, palpitations
• abdominalpain
• maymimicCHF(especiallyright-sidedHF)
■ ascites, hepatosplenomegaly, edema
• increasedJVP,Kussmaul’ssign(paradoxicalincreaseinJVPwithinspiration),Friedreich’ssign
(prominent “y” descent)
• BPusuallynormal(andusuallynopulsusparadoxus)
• precordialexamination:±pericardialknock(earlydiastolicsound) • seeTable17fordifferentiationfromcardiactamponade
Investigations
• ECG:non-specific–lowvoltage,flatTwave,±AFib
• CXR: pericardial calcification, effusions
• echo/CT/MRI:pericardialthickening,±characteristicecho-Dopplerfindings
• cardiaccatheterization:equalizationofend-diastolicchamberpressures(diagnostic)
Treatment
• medical:diuretics,saltrestriction
• surgical:pericardiectomy(onlyifrefractorytomedicaltherapy)
• prognosisbestwithidiopathicorinfectiouscauseandworstinpost-radiation;deathmayresultfrom
Cardiology and Cardiac Surgery C47
Classic Quartet of Tamponade
• Hypotension
• Increased JVP
• Tachycardia
• Pulsus paradoxus
Beck’s Triad
• Hypotension
• Increased JVP
• Muffled heart sounds
DDx Pulsus Paradoxus
• Constrictive pericarditis (rarely)
• Severe obstructive pulmonary disease (e.g.
asthma)
• Tension pneumothorax • PE
• Cardiogenic shock
• Cardiac tamponade
heart failure
Table 17. Differentiation of Constrictive Pericarditis vs. Cardiac Tamponade
Characteristic
JVP
Kussmaul’s sign Pulsus paradoxus Pericardial knock Hypotension
Constrictive Pericarditis
“y” > “x” Present Uncommon Present Variable
Cardiac Tamponade
“x” > “y” Absent Always Absent Severe