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CARDIO:PERICARDIAL DISEASES
Pericardial Diseases
Pericardium
Visceral and Parietal Pericardium
Visceral pericardium is a serous membrane separated from the
parietal pericardium by a small quantity (15-50ml) of fluid.
Inside the pericardial cavity (space between visceral and parietal
pericardium) is pericardial fluid of about 50-70cc (ibasa notes)
Functions of Pericardium
1. Prevents sudden dilation of the cardiac chambers during exercise
and with hypervolemia
2. Restricts the anatomic position of the heart
3. Minimizes friction between the heart and surrounding structures
4. Prevents displacement of the heart and kinking of the great vessels
5. Retards the spread of infections from the lungs and pleural cavities
Acute Pericarditis
Definition
inflammatory process involving the pericardium
results in a clinical syndrome with triad of chest pain, pericardial
friction rub, and changes in the ECG
so for pericardial diseases actually were talking about
inflammation and we call that pericarditis. And this pericardial
inflammation can be acute or chronic. And that inflammation may
have complications later and these are as follows:
pericardial effusion or
constrictive pericarditis
Pericardial effusion may be small in amount or large in amount, if it
is in large amount it may become what you call cardiac tamponade
disorders.
So basically the problem in pericardium is inflammation and that
inflammation can later produce effusion and then constriction.
2014-2015
Dr. Bartolome
Essentials of Diagnosis
Central chest pain aggravated by coughing, inspiration, or
recumbency
Pericardial friction rub on auscultation
Characteristic ECG changes
Prevalence
Admitting diagnosis in 0.1% of hospital admissions
More common in men than in women
In pericarditis class, there is chest pain but you must remember that
when you see a patient having a chest pain you should know the
risk probability of the patient having that condition.
Eto, katuladnitongbatangetopag nag-chest pain (simiki? )
anongiisipinnyo? Iisipinnyobana may ischemic heart disease sya?
Unlikelydiba? Thats why you always have to remember the risk
factors for the development of heart disease.
Hindi nyodapatkinakalimutanang modifiable and non-modifiable
risk factors diba?
So what are the modifiable risk factors?
Hypertension
DM
Hyperlipidemia
Smoking
obesity
Sedentary lifestyle
And the non-modifiable risk factors are as follows:
45 yo male or 55 yo female
Early history of CAD
Eto, katuladnito (miki again?) pwede bang ischemic heart disease
yan? Rheumatic heart disease pwede pa.
At the ER you should be able to diagnose ischemic heart disease
within 10min., and then do the PE you have to rule out allthe
things that can cause death.
Anobayung chest pain napwedengmamatayyung patient mo?
Myocardial ischemia or infarction
Pneumothorax
Aortic dissection
Acute pulmonary embolism
All of these can cause acute chest pain and dyspnea and all are life
threatening condition.
Then, history, risk factors, diba?
Prolonged chest pain, more than 20 minutes will you consider it to
be MI? How do you diagnose a patient with MI? 1, 2, 3 anoyun?
Prolonged chest pain of more than 20 min
You have to request for ECG and lastly
Cardiac enzymes
So how about pulmonary embolism? Another term for acute PE is
acute corpulmonale. So you know that there is a risk for developing
DVTanobayungmga risk factors for developing DVT? Patients who
are immobile, have prosthesis, those who underwent orthopedic
surgery, cancer patientsand then all of a sudden may dyspnea
so, where will that be lodge? SaPulmonary artery, thats why it is
called pulmonary embolism. So, when you obstruct the pulmonary
artery what will happen next? Youll end up having pulmonary
arterial hypertension, R ventricular hypertension, and venous
hypertension.So what is the physical examination? So you end up
having R sided PE findings like neck vein engorgement in a patient
who is hypotensive???
Another thing that you have to rule out is the possibility of having
pneumothorax, what do you expect to see? There is lagging of the
affected side; by percussion will you be able to appreciate
pneumothorax? There will be what? Hyper-resonance on the
 affected side; now in auscultation? There will be absence of breath
sound on the affected side. Thats why in the ER you request for ECG
and Xray. Peronakitamonahindinagumagalaw, anonguunahinmo,
ECG or Xray?
Sa aortic dissection? What is the presentation? Prolonged chest
pain masyadongmatagal like 2 hours or 3 to 4 hours. What is the
PE finding of aortic dissection that differentiates it with other
diseases mentioned? You have to palpate the pulses. Patients with
aortic dissection haveassymetrical pulse, but with normal ECG. You
can also request for chest Xray. Anongmakikitanyo? Theres
widening of the mediastinum.
So yanyungsinasabikosainyonaapatnapwedemagcausengdeath, but
not acute pericarditis.
Common Causes of Pericarditis and Pericardial Effusion
Idiopathic the most common cause is idiopathic in origin. The
problem is that probably most of these are secondary to viral
infection. Its very hard to document a viral infection. Sino
nanakakitasainyong viral titer result?Nakikitakolangsalibro. Thats
why probably this idiopathic cause is due to viral infection. Puro
clinical tayosapinas.
Infectious bacterial, viral, fungal, HIV
Myocardial Infarction
Radiation
Postoperatively after open heart surgery
Chest trauma blunt, sharp
Malignancy
1o Mesothelioma, angiosarcoma
Metastatic lung, breast, bone, lymphoma, melanoma
Collagen vascular disease RA, SLE
Metabolic uremia, hypothyroidism
Pharmacologic penicillin, phenytoin, procainamide, hydralazine,
minoxidil, cromolyn Na, methysergide, doxorubicin
Para saanang hydralazine? Hydralazine is for
hypertension specifically for pregnant patient.
Cromolyn Na for allergy. You must be careful.
Signs and Symptoms
Most common symptom: chest pain
- Described as pleuritic in nature.
- severe, sharp, retrosternal
- often radiating to the neck, shoulder, or back
- worsens in the supine position and with inspiration
- Improved with sitting upright and leaning forward but not always
present.
- Now, dont forget your PPQRRST, for any kind of pain you use this
as a guide. You can do this in 1 minute.
- How will you differentiate MI from unstable angina pectoris? Thats
why it is important to use that guide.
Friction Rub
- Scratchy, grating, high-pitched friction rubs (squeak of leather of
a new saddle)walangkabayosi doc so hindinyaalamyan
- Due to fibrous deposits in the pericardial space
- With three components:
1. atrial systole
2. ventricular systole
3. early ventricular diastole
- best heard during inspiration at left lower sternal border, with
patient leaning forward
- Thats why pagnagPE kayo you always have to do this. Actually this
is the best position for you to appreciate aortic and pulmonic
sounds and also at the same time the friction rub.so you have 3.
- Ano daw Brazilian? LOL Si Santillan girl or boy? waaaah!
Specific Types
Idiopathic Pericarditis
Cause difficult to establish
Most common diagnosis
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Viral Pericarditis
Most common causes: coxsackievirus B, echovirus usual cause of
sipon and uboubonyo.
4-fold increase in antiviral titer required for diagnosis
withprodrome of URTI mga 1-2 weeks that later complaints of
severe pleuritic chest pain.
Prognosis good usually self-limited
Purulent Pericarditis
This is the one that causes problem compared to viral in origin.
Predisposing Factors:
1. Thoracic Surgery
2. Chemotherapy
3. Immunosuppression
4. Hemodialysis
Acute onset: high fever, chills, night sweats, dyspnea; chest pain or
friction rub rare
Cardiac tamponade common (42%-77%) dont forget that
purulent pericarditis is associated with cardiac tamponade. You
really need to document if it is really purulent.
Paanomosususpentyahinna may purulent pericarditis yan? So,
yanyungmga people prone to have infection later developing
cardiac tamponade. Once you have cardiac tamponade it is a
medical emergency. Additional medical emergency,
kaninaapatdiba? Oh, plus one!
High mortality rate kasiyungmga patient immunosuppressed.
Hospital admission with immediate pericardiocentesis + IV broad
spectrum antibiotics mandatory followed by early surgical
drainage.
Kailangantanggalinyung fluid agad and then give anitbiotics.
Tuberculous Pericarditis
1%- 2% of cases of PTB
Increased risk in patients who are immunocompromised or HIV (+)
if patient have Tuberculous pericarditis, you always have to rule
out the possibility of having HIV. Actually for patient suffering from
TB not in Philippines, the probability that that patient is suffering
from HIV is very high! More than 30-40%. Sa US now, pag positive
TB ka, kahit PTB lang, automatic nagpapoHIV test na din sila. Satin,
hindikapinoypagwalang TB. LOL
Slow development of non-specific symptoms; chest pain and
friction rub often absent
Chest radiography useful when findings of PTB present
Hospital admission indicated + anti-TB therapy (e.g. Rifampicin,
INH, streptomycin, ethambutol) started promptly
Pericardial fluid analysis: very high specific gravity, very high
protein (>6 g/dL), & predominantly lymphocytic cells
Pericardial biopsy with acidfast bacilli PCR recommended
Uremic Pericarditis
Incidence: 6%-10% of patients with advanced renal failure before
initiation of dialysis
BUN usually >60 mg/dL
Large hemorrhagic effusion due to impaired platelet function
common
Dialysis indicated
Dialysis - Associated Pericarditis
An irony, since patient with uremic pericarditis needs dialysis.
The main problem here is inadequate dialysis treatment.
Ditokasisapinas 2x a week lang, and ideally dapat minimum of 3x a
week yan.
Cause by fluid overload fluid usually serous
Intensification of hemodialysis indicated
Improvement in 1-2 weeks
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 Treatment is give NSAID peropwedeng acute pericarditis yun
Post MI Pericarditis because of the trauma, but one thing about costochondritis is you
can localize the pain now.
Common complication in patients with MI (25%-40%)
1. within 3-10 days after MI Diagnosis
2. development correlates with extent of necrosis
more frequent with anterior than inferior infarcts Remains a clinical diagnosis based on:
Happens esp. in large anterior infarction, so pag may post MI 1. History
pericarditis ka, ibigsabihin nun malakiang infarction. The size 2. PE
depends on what artery is affected. 3. ECG there is typical ECG changes in acute pericarditis.There is
associated with a higher 1-year mortality rate and incidence of CHF diffuse ST segment elevation in acute pericarditis. Dibarinurule out
Diagnosis requires: natinsyasa MI? anobayungsa MI, diffuse or localized? Localized. It
1. Symptoms or a new pericardial friction rub only involves the arterial supply affected. Remember anatomy.
2. ECG changes Aside from that, there is also PR segment depression in acute
typical ST elevation seen with acute pericarditis pericarditis. In MI, it doesnt happen except if you have auricular
persistently positive T waves more than 2 days post-MIor infarction.
normalization of previously inverted T waves Other imaging studies: CT scan, MRI, Echocardiography not really useful
so, pericarditis has chest pain, what differentiates it from MI? except if with pericardial effusion.
one is pleuritic the other is not
MI has ECG changes while pericarditis none
Another is Cardiac enzyme but you have to know its
release pattern.
CKMB 6-8hours present in blood; peak- 24-
48 hours and would last for 72 hours
Troponin T/I - 6-8hours present in blood;
peak- same but would last for 10-14 days
Can I use trop T if may chest pain on 5th day? No. kasi
positive pa sya. You will use CKMB, kasiwalanasya after
3 days. (diko gets, pabasana lang.)
Actually class if you have to request for cardiac
enzymes, dapat serial yun, 0, 6, 12, and 14. Kaya
langpagsiguradonayung doctor hindinasiniserial.
Pagnatitipid pa yun, kungnakitanana may ST elevation
yunhindinamagrerequestyun.

Post Cardiac Injury Pericarditis

Dresslers syndrome
occurs 2-3 weeks after MI or open heart surgery
Autoimmune component and possibly a latent viral infection
implicated
consists of pleuritic chest pain, fever, leukocytosis, and a
pericardial friction rub

Malignancy - Associated Pericarditis

caused mostly by metastatic disease mostly with tumor

metastatic to the heart. Nagkakaroonnang cardiac tamponade
physiology.
Bronchogenic or breast carcinoma, Hodgkins disease and
lymphoma are common you have to rule this out immediately.
Diagnosis is based on analysis of pericardial fluid cytology
sensitivity ranging from 70% to 90%
specificity of up to 95% to 100%

Radiation Pericarditis

Recent or remote mediastinal radiation

Any time from weeks to months after the exposure
Paminsannakaligtaan to. Pag may history ng malignancy yung
patient mo, dont forget to ask if nagkaroonbang radiation
treatment before. Can be used as ddx. - In AP, concave. In MI convex, payong.

Trauma Pericarditis

May accompany sharp or blunt trauma and even a minimally

invasive procedure such as cardiac diagnostic or interventional
catheterizations
Iba pa yungcostochondral fracture/ inflammation

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Stage I Acute Pericarditis Colchicine for persistent or refractory cases of
Dresslers syndrome and idiopathic pericarditis
Anticoagulants avoided during acute phase reduce
bleeding and tamponade
Pericardiectomy
Indications:
1. development of pericardial constriction
2. recurrent pericarditis rare
most definitive procedure
30-day perioperative mortality rateis about 5%

Outcome

Patients with uncomplicated acute pericarditis should have regular

follow-up after the initial visit to ensure resolution of symptoms
and rule out the development of constrictive symptoms.

PERICARDIAL EFFUSION
Myocardial Infarction Definition

increased amount of pericardial fluid

Essentials of Diagnosis

echocardiographic demonstration of pericardial fluid

Echocardiogram- to confirm the diagnosis

Acute Pericarditis: Chest Radiography

May be entirely normal unless there is a pericardial effusion
causing cardiomegaly or changes caused by underlying disease

Acute Pericarditis: Echocardiography

Indications:
1. symptoms persisting for longer than 1-2 week
2. presence of hemodynamic abnormalities
3. clinical suspicion of a large or increasing pericardial effusion, or
4. recent cardiac surgery

Treatment

most cases uncomplicated and self-limited kahitwalanggagawin,

but dont forget that acute pericarditis is with pain and
inflammation. So, what can you give to reduce pain and
inflammation? So you give drug with analgesic and anti-
inflammatory property. And that is NSAIDs. Most common causes of large effusions are:
Indications for an imaging modality, hospital admission, or both: 1. Malignancy (25% of cases)
1. clinical suspicion of a large effusion
2. Infection (27%) most common cause is secondary tuberculosis
2. hemodynamic instability
3. Collagen vascular disease (12%)
3. severe pain or other symptoms
4. suspicion of a serious underlying condition, or 4. Chest radiation (14%)
5. any other signs or symptoms of clinical instability or Most common Cardiovascular manifestation of acquired immunodeficiency
impending deterioration syndrome worse outcome ( BOARD EXAM QUESTION)
HIV + pericardial effusionassociated with poor prognosis,
Medical Management WHY? Actually it is not secondary to AIDS that produces Pericardial
Treatment of underlying disease- mainstay inflammation,
NSAIDs for pain relief it its secondary to secondary problem of HIV infection
1. Ibuprofen 400 mg q8h , it is secondary to pneumocystis or Kaposi sarcoma or tb going to
2. Ketorolac tromethamine parenteral pericardium,
3. Contraindicated in the early period (<7-10 days) after MI (may so ibig sabihin niyan talagang highly immunosupress yung patient,
predispose to cardiac rupture) use aspirin instead why? konting sipon lang ng rhinovirus, deads na!
You give it as an anti-inflammatory drug and as an
antithrombotic, not as analgesic.
Prednisone high dose taper over 3 weeks
1. if pericarditis recurs (20%-30% of patients OR
2. response to NASAIDs is poor

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 Pathophysiology

Pericardial sac normally contains 15-30 ml of fluid can hold 80-200ml

of fluid acutely and even up to 2L if the fluid accumulates slowly
development of tamponade depends on the rate of accumulation rather
than on the volume of the effusion typically, signs of right ventricular
diastolic failure develop first, followed by left-sided symptoms

Symptoms

Arise from the compression of surrounding structures (lung, stomach, phrenic

nerve) or diastolic heart failure
Include:
1. Chest pressure or pain
2. Dyspnea
3. Nausea, abdominal fullness, and dysphagia
4. Phrenic nerve irrirtation may cause hiccup Echocardiography
Hiccup- merong patient dati hiccup ng hiccup, wala daw nagtatanong Echo-free space between visceral and parietal pericardium the
sa PE, eh yung patient nag underwent nuclear ablation of thyroid extent of the space defines the size of the effusion
gland,
Large effusions may produce the picture of a swinging heart
so pinaxray, ang laki ng heart! Yun pala yung patient is suffering
severe hypothyroidism tapos walang nagbother to look up the neck Imaging modality of choice for diagnosing a pericardial effusion
, eh 1 week na yung patient, nalusutan na daw lahat, yung but may miss small loculated effusions
clerk,intern, 3 residents, and even the consultant and the another
consultant., eh nagtamponade yung patient, Sizing of Small Medium Large
Kaya daw ipractice yung P.E.. may medical officer pang di nag PE, Pericardial
tapos after 1 hr, deads yung patient. Effusion by
NO ONE CAN ARGUE ON YOUR PE,! In short mag P.E. or change your Echocardiogra
course.( halerrrr!!! Third year na kaya! ) phy Size
Vol (ml) <100 100-500 >500
Physical Examination Localization Localized Circum- Circum-
ferential ferenial
Small effusion PE unremarkable ,asymptomatic Width <1 1-2 >2
Large effusion:
1. Muffled heart sounds Analysis of Pericardial Fluid
2. Ewarts sign (dullness to percussion, bronchial breath sounds, and egophony 1. CBC
below the angle of the left scapula) rare 2. Chemistry panel
3. With increasing volume of the effusion, signs and symptoms of cardiac 3. ESR
tamponade may occur
Diagnostic pericardiocentesis done if the cause is unclear or any of the
Diagnosis following is suspected
1. Malignancy
Electrocardiography 2. TB
Low voltage & electrical alterans 3. Fungal or bacterial infection

Therapeutic pericardiocentesis done for large effusions that are

increasing in size or causing tamponade

Diagnostic pericardiocentesis done if the cause is unclear or any of the

following is suspected
1. Malignancy
2. TB
3. Fungal or bacterial infection
Therapeutic pericardiocentesis done for large effusions that are increasing in
size or causing tamponade

Chest Radiography
Cardiomegaly occurs if there is more than 250 ml of fluid in the
pericardial sac

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Exudate vs. Exudate Transudate Pericardial tamponade end up in having Venous Hypetension
Transudate
Parameter Essentials of Diagnosis
Cause Malignancy Radiation
Infectious, Uremia Increase jugular venous pressure with an obliterated y descent
parainfectious Hypothyroidism Pulsus paradoxus
Postpericardiotomy Trauma Echocardiographic evidence of right atrial and ventricular collapse
syndrome
Equal diastolic pressures in all four cardiac chambers
Collagen vascular
disease
Spg (g/ml) >1.015 <1.015 Pathophysiology
Elevated intrapericardial pressure progressive limitation of mostly early
Total protein >3.0 <3.0
diastolic ventricular filling low cardiac output
Fluid-to-serum >0.5 <0.5
protein ratio
Symptoms
Fluid-to-serum LDH >0.6 <0.6
Symptoms resulting from decreased cardiac output and congestion:
Fluid-to-serum <1.0 >1.0 dyspnea,
glucose ratio
chest discomfort
weakness restlessness
Treatment
Agitation
Medical Management
Diuretics help decrease the intensity of fluid overload symptoms if present Drowsiness
Effusions causing pretamponade or tamponade immediate drainage Oliguria
Volume expansion and inotropic for hemodynamic stabilization pending anorexia
drainage If the tamponade develops acutely as a complication of an acute MI (free
wall rupture) or trauma catastrophic, with sudden death or shock and
Pericardiocentesis high mortality
Echocardiographically guided pericardiocentesis is safe and
effective Physical Examination
Indications: Classic findings Becks triad (10% to 40% of patients):
1. A large effusion with hemodynamic compromise or tamponade 1. Hypotension
2. For diagnostic purposes 2. JVD
3. Muffled heart sounds
Surgical Treatment Manifestations are right sided(neckvein engorgement,ascites, and
1. Percutaneous Balloon Pericardiotomy bipedal edema)
Least invasive Other things that produced your massive pleural effusion
Used mostly for neoplastic effusion with a poor prognosis as a can also produce these clinical manifestations such as muffling of
palliative treatment
the heart sound bec of that fluid
Success rate for relieving re-accumulation of pericardial fluid is 85%
Since there is fluid in between the precordium, dati kasi walang
to 92% at 30 days
2. Subxiphoid Pericardiostomy fluid, now there is a large fluid , it will muffles the heart sound s the
Known as a pericardial window transmission on the stethoscope Muffling of the heart sound-
May be done under local anesthesia humihina yung heart sounds to the point na hindi mo marinig
High success rate, with few complications talaga.
Recurrence of fluid accumulation is rare
Ewart sign- dullness to percussion ,brochial breath sound
Cardiac Tamponade ,egophony in the angle of scapula-
Definition where will you look for this sign?BACK,LEFT, kasi andun yung
heart... lumaki yung cardiac silhouette , so nacompress yung
Occurs when fluid accumulation in the finite pericardial space lungs cardiac t
causes an increase in pressure, with subsequent cardiac
compression and hemodynamic compromise Ewart's sign is a set of findings on physical examination in people
Pag nagka effusion,lalaki yan,magkakaroon ng pericardial space with large collections of fluid around their heart (pericardial
with fluid inside, effusions).
and thats fluid inside will have increase intracardial pressure Dullness to percussion (described historically as "woody" in
quality), egophony, and bronchial breath sounds may be
and it will compress the heart.
appreciated at the inferior angle of the left scapula when the
In the left heart, which is much thicker than your right heart,
effusion is large enough to compress the left lower lobe of the lung,
and thats why when you have compreesion, the one that will be causing consolidation or atelectasis.
easily compress is your right side of the heart( the right ventricle
and the right autirum) Tachycardia, tachypnea, hepatomegaly common
It will not allow blood flow coming from the veins going to the Pulsus paradoxus inspiratory decline in systolic BP of more than 10
right atrium and right ventricle mmHg due to compression and poor filling of the LV caused by
And it will Decrease preload, decrease CO, Decrease BP and as increased venous return to the right side of the heart
-during inspiration tapos medyo nawala-wala pait is pulsus
compensatory mechanism it will dec your heart rate Pericardial
paradoxus or alterans
tamponade with Tachycardia
Since your not allowing blood flow from great arc veins going to
right atrium venous hypertension

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 Hyoptension, neck veing engorgement, muflled heart
sound + narrow pulse pressure+ pulsus paradoxus
Pericardial tamponade(MEDICAL EMERGENCY)

Diagnosis
Electrocardiography
Abnormal findings may include:
1. Electrical alternans - height of QRS varies like 3 mvolt, 5,8 millivolts.
Check the height of ECG.
It is commonly seen on pt with neck vein engorgement,
cardiomegalySUSPECT CARDIAC TAMPONADE
Massive pericardial effusion
you need at least 250 cc of pericardial fluid for you to
produce Cardiomegaly secondary to Pleural effusion,
Cardiothoracic ratio of >0.5 or something like 0.7
Typical water bottle configuration

2. Low voltage
3. Changes associated with acute pericarditis
Since there is a fluid in between the transmission of electrical potential
going to the ECG DOUBLE lean lead ecg? ??? ano d daw? Sorry ..
QRS is small
Lean? Leads- at least 5 millivolts( para hind maconsiderdouble...)
Chest lead- V1-V6- 5 millivolt;
Lead II and V -7 millivolts
Lead 3 and 4 9millivolts
IF hindi ganito yung value, we can consider na meron Double ...

Transthoracic Echocardiography
Sensitive finding for tamponade physiology is inferior vena
cava plethora, with absent inspiratory collapse
Pericardial Constriction/ Constrictive Pericarditis
Right ventricle and atrial collapse on echocardiography is the
most accurate finding for diagnosis Definition
ECHOCARDIOGRAPHY- confirms the dx of pericardial
effusion and cardiac tamponade and to the point that An abnormal thickening of the pericardium, resulting in impaired
effusion is called swimming heart ventricular filling and decreased cardiac output
Most cases idiopathic
Right Heart Catheterization May have history of acute or chronic pericarditis
Most typical finding: equalization of mean right atrial, right ventricular
and pulmonary artery diastolic, and mean pulmonary capillary wedge Essentials of Diagnosis
pressures. Markedly elevated JVP with accentuated x and y descent and
Kussmauls sign
Treatment Kussmauls sign- enlargement of neck vein during deep inspiration (
Medical emergency Normal:collapsed neck vein )
Remove the fluid Kussmaul's sign is a paradoxical rise in jugular venous
Immediate hospital admission and prompt pressure (JVP) on inspiration.
pericardial drainage by pericardiocentesis It can be seen in some forms of heart disease and is
If follow-up echocardiography documents fluid re-accumulation usually indicative of limited right ventricular filling due
pericardial window should be considered to right heart failure.
Infection risk associated with a pericardial drain increases after 48 hours Pericardial knock on auscultation
MRI, CT or echocardiographic imaging showing a thickened
Differential Diagnosis pericardium
1. Right-sided heart failure
2. Right ventricular infarction
3. Constrictive pericarditis Pathophysiology
4. Pulmonary embolism
Initiating event causes a chronic inflammatory pericardial process fibrinous
Treatment thickening & calcification of pericardium limitation of intrapericardial
Immediate hospital admission and prompt pericardial drainage by volume impaired ventricular filling decreased cardiac output right and
pericardiocentesis left ventricular failure
If follow-up echocardiography documents fluid re-accumulation
pericardial window should be considered
Infection risk associated with a pericardial drain increases after 48
hours

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Calcification of the pericardium by CT

Physical Examination
Increased ventricular filling pressures cause:
1. Jugular vein distention
2. Kussmauls sign absent inspiratory decline of jugular venous distention
Auscultation: muffled heart sounds and occasionally a
characteristic pericardial knock (60-200 milliseconds after the
second heart sound)

Diagnosis
ECG
Non-specific but low voltage of QRS complex may be seen

Laboratory tests
Brain natriuretic peptide (BNP) serum biomarker; distinguish
constrictive from restrictive pericarditis higher in resetrictive

Echocardiography
Best imaging modality for assessing
hemodynamic parameters non-invasively
Doppler echocardiographic
findings have the highest sensitivity and specificity for detecting
constrictive physiology

MRI & CT
CT is the imaging modality of choice to evaluate the
pericardium
Pericardial calcifications may easily be identified on CT
Finding of thickened pericardium on the CT or MRI is specific
for constriction

Treatment
Medical treatment is difficult and does not affect the natural
progression or prognosis of the disease
Diuretics and a low-sodium diet for patients with mild to moderate
(New York Heart Association [NYHA] Class I or II) symptoms or
contraindications to surgery
For most patients, pericardiectomy is advised, with 80% to 90% of
patients experiencing improvement and 50% complete relief of
symptoms
remove the pericardium

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