Medical Archive

Normal functions of the pericardium

Acute pericarditis

Etiology

???	Virus (Coxsackie A,B), Tb
????	MI, RF, uremia
??/????	Rheumatic fever, SLE

Diagnosis

Symptom

Pleuritic chest pain (??? ??? ??)

Sign

Pericardial friction rub
Elevated JVP
Muffled S1/S2
Pulsus paradoxus (a ?in SBP >10mmHg on inspiration)

EKG

• Electrical alternans with sinus tachycardia
• Diffuse PR depression
  • d/t inflammation of atrial myocardium
• Diffuse ST elevation
  • d/t inflammation of ventricular myocardium.
  • Upward concave ST. No reciprocal change

CXR

Water bottle appearance ? pericardial effusion

ECHO

Echo-free space ? pericardial fluid? ??? tamponade?? ??

Treatment

• ???? ???? ?? – tamponade ?? ??.
• Admission indication
  • ??, ??, ???? ??? ??, ??, ?? ?? ? ?? ?? ?? ??.
• Pericardiectomy indication
  • ?? ???? ?? ?
  • 2??? ??
  • Steroid?? ?? x

Acute idiopathic pericarditis

• 70~90%? ????? ??? ??. ???? ? ??? ??? ???
• Aspirin 2-4g/d with GI protection
• NSAID (ibuprofen or indomethacin)
• Colchicine
  • ??? ?? ?? ??? ? ??. NSAIDs? ??? ???? pericarditis ??? ??.
  • ??? ? ??? ?? ? ??. S/E: diarrhea
• Prednisone
  • NSAID+colchicine?? ??? ?? ??
  • 1mg/kg/d -> tapering

Pyogenic pericarditis

??? ?? ?? ??? ??. ??? ??? ??

Uremic pericarditis

NSAID? ?? ??? ??? ?? (?? ???? ?? ??)

TB pericarditis

????. Steroid? controversial.

Cardiac tamponade

• ??: Neoplasm, Tb, Idiopathic pericarditis, Uremia

Clinical findings

• Acute
  • Minutes to hours
  • 100-200mL
  • Normal cardiac silhouette
• Subacute
  • Days to weeks
  • 1-2L
  • Enlarged, globular cardiac silhouette
• Physical exam
  • Beck triad: BP ?, JVP ?, muffled heart sounds
  • Pulsus paradoxus
  • Prominent x, absent y (atrial emptying? ?? ???. RV infarct??? ??? ?? ???)

Evaluation

• ECG: Low voltage, ST elevation, electrical alternans (heart swing)
• CXR: water bottle appearance

Management and prognosis

• Pericardiocentesis, ? ??? IV saline? preload ??!!
• 1/3? constrictive pericarditis?. 

Viral or idiopathic acute pericarditits

Differential diagnosis

# Malignant pericardial effusion

• Common primary tumors
  • Lung, breast, GI tract, lymphoma, melanoma
• Management
  • Acute: pericardiocentesis, cytologic fluid analysis
• Prevention of recurrence
  • Prolonged drainage (eg, catheter, pericardial window)

Chronic pericardial effusion

Chronic constrictive pericarditis

Etiology

• Developing countries & endemic areas (eg, Africa, India & China)
  • Tuberculosis is a common cause.
• United states
  • Idiopathic or viral (>40%), radiation therapy (~30%), cardiac surgery (~10%), connective tissue disosrders.

Clinical and laboratory findings

• ??
  • Acute pericarditis? effusion ????? granuloma ??
  • 4 chamber? ???? ?? ??, ???(equilibration)
  • Edema ??. But RV? ???? ?? ?? ??? Pul. Edema? ??.
• ??
  • Pericardial knock
    • Brief, high-frequency, precordial sound 
    • Early diastole: shortly after S2, before S3 – maybe confused with opening snap
  • Kussmaul’s sign, low volage of QRS on ECG
  • Prominent x & y, Square root
  • CXR: pericardial calcification

Differential diagnosis

Treatment

• Pericardiectomy, ????/diuretics, Anti-Tb