©2011 David Stultz Pericardial Diseases

©2011 David Stultz

Pericardial Pericardial

DiseasesDiseases

David Stultz, MD, FACCDavid Stultz, MD, FACC

July 19, 2011July 19, 2011

www.drstultz.com

©2011 David Stultz

©2011 David Stultz

Goals of ConferenceGoals of Conference

�� Identify signs and symptoms of Identify signs and symptoms of

pericardial diseasespericardial diseases

��Discuss workup and treatment Discuss workup and treatment

strategies for pericarditisstrategies for pericarditis

�� List common causes of pericarditis List common causes of pericarditis

and pericardial effusionand pericardial effusion

©2011 David Stultz

The PericardiumThe Pericardium

�� Outer fibrous layerOuter fibrous layer

�� Inner lining (serous)Inner lining (serous)–– Visceral pericardium Visceral pericardium (epicardium)(epicardium)

–– Parietal pericardium Parietal pericardium lines outer fibrous lines outer fibrous layerlayer

�� Pericardial space is Pericardial space is in between visceral in between visceral and parietal and parietal pericardiumpericardium–– Normally 15Normally 15--50mL of 50mL of fluidfluid

©2011 David Stultz

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, social No significant medical, family, social historyhistory

�� No medicationsNo medications

�� Physical Exam unremarkablePhysical Exam unremarkable

©2011 David Stultz

Case #1 EKGCase #1 EKG

©2011 David Stultz

Laboratory DataLaboratory Data

��WBC 12.8WBC 12.8

��Renal panel normalRenal panel normal

�� LDL 113LDL 113

�� Troponin I 4.0Troponin I 4.0

��CPK 240, CKCPK 240, CK--MB 21.8 (index 9.1%)MB 21.8 (index 9.1%)

©2011 David Stultz

What is the most likely diagnosis?What is the most likely diagnosis?

1.1. Acute myocardial infarctionAcute myocardial infarction

2.2. Acute pericarditisAcute pericarditis

3.3. Acute myopericarditisAcute myopericarditis

4.4. Constrictive pericarditisConstrictive pericarditis

5.5. Pericardial tamponadePericardial tamponade

©2011 David Stultz

What would you do next?What would you do next?

1.1. Cardiac CatheterizationCardiac Catheterization

2.2. EchocardiographyEchocardiography

Or go straight to treatment without Or go straight to treatment without

imaging:imaging:

3.3. High dose NSAIDSHigh dose NSAIDS

4.4. High dose NSAIDS + ColchicineHigh dose NSAIDS + Colchicine

5.5. PrednisonePrednisone

©2011 David Stultz

Now What Would You Do For Now 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 q6h

3.3. 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

©2011 David Stultz

What is the Most Common Cause What is the Most Common Cause

of Acute Pericarditis?of Acute Pericarditis?

1.1. Idiopathic/ViralIdiopathic/Viral

2.2. BacterialBacterial

3.3. MalignancyMalignancy

4.4. UremiaUremia

5.5. Acute Myocardial InfarctionAcute Myocardial Infarction

6.6. Autoimmune diseaseAutoimmune disease

©2011 David Stultz

Acute PericarditisAcute Pericarditis

�� Inflammation of PericardiumInflammation of Pericardium

��Symptoms include sharp chest painSymptoms include sharp chest pain

��Often improved with upright Often 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.

©2011 David Stultz

Common Causes of Acute Common 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.

©2011 David Stultz

Rare Causes of Acute PericarditisRare Causes of Acute Pericarditis

��After cardiotomy or thoracic surgeryAfter cardiotomy or thoracic surgery

��Aortic dissectionAortic dissection

��Chest wall traumaChest wall trauma

��Chest wall irradiationChest wall irradiation

��Adverse 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.

©2011 David Stultz

Diagnostic Criteria for PericarditisDiagnostic Criteria for Pericarditis

�� Two of Four criteriaTwo of Four criteria

–– Characteristic chest painCharacteristic chest pain

–– Pericardial friction rubPericardial friction rub

–– Suggestive EKG changesSuggestive EKG changes

–– New or worsening pericardial effusionNew or worsening pericardial effusion



©2011 David Stultz

Pericarditis Chest PainPericarditis Chest Pain

��Sudden onsetSudden onset

��RetrosternalRetrosternal

�� Pleuritic/SharpPleuritic/Sharp

��Worse with inspirationWorse with inspiration

�� Improved when sitting up or leaning Improved when sitting up or leaning

forwardforward

��Chest pain can radiateChest pain can radiate



©2011 David Stultz

Pericarditis Friction RubPericarditis Friction Rub

�� Caused by rubbing of inflamed visceral and Caused by rubbing of inflamed visceral and parietal pericardiumparietal pericardium

�� Variable over timeVariable over time

�� Present in 85% of patients with pericarditis at Present in 85% of patients with pericarditis at some pointsome point

�� High pitched scratch or squeak at left lower High pitched scratch or squeak at left lower sternal 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


http://depts.washington.edu/physdx/heart/tech5.html

©2011 David Stultz

Pericarditis EKG ChangesPericarditis EKG Changes

�� Diffuse ST segment elevation and PR segment Diffuse ST segment elevation and PR segment depressiondepression

�� 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)



©2011 David Stultz

Laboratory Studies in PericarditisLaboratory Studies in Pericarditis

�� Nonspecific elevation of inflammatory markersNonspecific elevation of inflammatory markers–– Erythrocyte sedimentation rate Erythrocyte 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 other ANA, Rheumatoid factor useful only if other autoimmune 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



©2011 David Stultz

MyopericarditisMyopericarditis

�� Predominantly pericardial involvement Predominantly pericardial involvement with associated myocardial with associated myocardial inflammation. inflammation.

�� Diagnosed after pericarditis diagnosed Diagnosed after pericarditis diagnosed and evidence of myocardial involvementand evidence of myocardial involvement–– Abnormal cardiac enzymesAbnormal cardiac enzymes

–– New onset of global or regional left New onset of global or regional left ventricular dysfunctionventricular dysfunction

�� Endomyocardial biopsy not neededEndomyocardial biopsy not needed

�� Approximately 17% of patients Approximately 17% of patients ultimately diagnosed with pericarditis ultimately diagnosed with pericarditis undergo heart catheterizationundergo heart catheterization

Salisbury 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.

©2011 David Stultz

Imaging StudiesImaging Studies

�� Chest XChest X--ray ray –– Usually not helpful unless Usually not helpful unless

there is a significant pericardial effusionthere is a significant pericardial effusion

�� Echocardiography Echocardiography –– Indicated for Indicated for

hemodynamic compromisehemodynamic compromise

�� Computed Tomography Computed Tomography –– useful to useful to

measure pericardial thickness (usually 1measure pericardial thickness (usually 1--

2mm) and pericardial effusion2mm) and pericardial effusion

�� Cardiac MRI Cardiac MRI –– Delayed gadolinium Delayed gadolinium

enhancement shows inflammation of enhancement shows inflammation of

pericarditispericarditis



©2011 David Stultz

Cardiac MRI of PericarditisCardiac MRI of PericarditisDelayed Gadolinium EnhancementDelayed Gadolinium Enhancement



©2011 David Stultz

Initial EvaluationInitial Evaluation

��History History

–– Any suggestion of malignancy or Any suggestion of malignancy or

autoimmune diseaseautoimmune disease

�� Physical ExaminationPhysical Examination

–– Friction rubFriction rub

–– Signs of TamponadeSigns of Tamponade

��Pulsus ParadoxusPulsus Paradoxus

��KussmaulKussmaul’’s signs sign

��BeckBeck’’s Triads Triad



©2011 David Stultz

Initial EvaluationInitial Evaluation

�� EKGEKG

��Chest XChest X--rayray

��CBCCBC

�� Erythrocyte Sedimentation Rate Erythrocyte Sedimentation Rate

and/or Cand/or C--Reactive ProgramReactive Program



©2011 David Stultz

Selected EvaluationsSelected Evaluations

�� Echocardiogram for hemodynamic Echocardiogram for hemodynamic compromisecompromise

�� 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



©2011 David Stultz

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.



©2011 David Stultz

Outpatient Outpatient ““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 with 3 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 pericarditis 4 (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 days 10 days predicted 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.

©2011 David Stultz

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 coronary Indomethacin not recommended in patients with coronary diseasedisease

�� ColchicineColchicine–– Use in conjunction with aspirin for 4Use in conjunction with aspirin for 4--6 weeks6 weeks

–– Caution with severe renal insufficiency, hepatobiliary Caution with severe renal insufficiency, hepatobiliary dysfunction, gastrointestinal motility disordersdysfunction, gastrointestinal motility disorders

�� CorticosteroidsCorticosteroids–– Reserved for patients failing initial therapy with Reserved for patients failing initial therapy with

NSAID+colchicineNSAID+colchicine

–– Increased risk of relapsing pericarditisIncreased risk of relapsing pericarditis

–– Consider using in Consider 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



©2011 David Stultz

COPE TrialCOPE Trial

�� 120 Patients with first episode 120 Patients with first episode pericarditispericarditis

�� ConventionalConventional–– ASA 800mg q6ASA 800mg q6--8h for 78h for 7--10 days with tapering 10 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--1mg 1mg 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, Trinchero R. 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.

©2011 David Stultz

Pericardiocentesis for PericarditisPericardiocentesis for Pericarditis

��Suspected etiologySuspected etiology

–– PurulentPurulent

–– TuberculousTuberculous

––Malignancy Malignancy

�� Persistent symptomatic pericardial Persistent symptomatic pericardial

effusioneffusion

Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary:

The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Eur Heart J.

2004;25(7):587-610.

©2011 David Stultz

Relapsing pericarditisRelapsing pericarditis

�� Usual first recurrence within 18 monthsUsual first recurrence within 18 months

�� IncessantIncessant–– Pericarditis returns within 6 weeks of treatment Pericarditis 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



©2011 David Stultz

Case #1Case #1

��Diagnosis: MyopericarditisDiagnosis: Myopericarditis

�� Treated with ibuprofen 800mg po Treated with ibuprofen 800mg po q8h x 5 days then 400mg po q12h x q8h x 5 days then 400mg po q12h x 5 days5 days

��Started on carvedilol 3.125mg po Started on carvedilol 3.125mg po q12hq12h

��Discharged after overnight Discharged after overnight hospitalizationhospitalization

��Doing well at 3 month followDoing well at 3 month follow--upup

©2011 David Stultz

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 months Fevers, chills, nausea, and vomiting 3 months agoago

�� Past medical historyPast medical history–– HypertensionHypertension

–– HyperlipidemiaHyperlipidemia

�� No pertinent medications, family or social No pertinent medications, family or social historyhistory

©2011 David Stultz

Case #2 EKGCase #2 EKG

©2011 David Stultz

CAT Scan of the ChestCAT Scan of the Chest

©2011 David Stultz

EchocardiogramEchocardiogram

©2011 David Stultz

©2011 David Stultz

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 ventricular Inspiration decreases right ventricular

pressure but increases left ventricular pressure but increases left ventricular

pressurepressure

�� May be acute, subacute, or chronicMay be acute, subacute, or chronic

–– Cardiac procedures are the most common Cardiac procedures are the most common

acute cause! acute cause!



©2011 David Stultz

DiagnosisDiagnosis

��Symptoms may include chest Symptoms may include chest

discomfort, shortness of breathdiscomfort, shortness of breath

�� Pulsus paradoxusPulsus paradoxus

–– Decrease in systolic blood pressure of Decrease in systolic blood pressure of

>10mmHg with inspiration>10mmHg with inspiration

�� Jugular venous distensionJugular venous distension

–– Normal x descent (atrial diastole) with Normal x descent (atrial diastole) with

blunted y descent (atrial systole)blunted y descent (atrial systole)



©2011 David Stultz

Echocardiography in TamponadeEchocardiography in Tamponade

��Right atrial collapse (late diastole)Right atrial collapse (late diastole)

��Right ventricular collapse (early Right ventricular collapse (early

diastole)diastole)

��Respiratory variation of Respiratory variation of

transvalvular inflow (i.e. the echo transvalvular inflow (i.e. the echo

pulsus paradoxus)pulsus paradoxus)

–– Tricuspid >40%Tricuspid >40%

––Mitral >25%Mitral >25%

©2011 David Stultz

Right Atrial CollapseRight Atrial Collapse

©2011 David Stultz

Tricuspid Valve Inflow with Tricuspid Valve Inflow with

Respiratory VariationRespiratory Variation

©2011 David Stultz

Mitral Valve Inflow with Mitral Valve Inflow with

Respiratory VariationRespiratory Variation

©2011 David Stultz

Treatment of TamponadeTreatment of Tamponade

�� IV fluids can be a temporizing measureIV fluids can be a temporizing measure

�� Ultimately need to evacuate fluidUltimately need to evacuate fluid–– Percutaneous pericardiocentesisPercutaneous pericardiocentesis

–– Surgical or percutaneous balloon pericardiotomySurgical or percutaneous balloon pericardiotomy

�� Analyze fluid (as clinically indicated) forAnalyze fluid (as clinically indicated) for–– Gram stainGram stain

–– Bacterial culturesBacterial cultures

–– AcidAcid--fast bacilli and culturefast bacilli and culture

–– CytologyCytology

�� In setting of aortic dissection, In setting of aortic dissection, pericardiocentesis should NOT be done!pericardiocentesis should NOT be done!



©2011 David Stultz

Pericardial effusion without 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 persists Consider pericardiocentesis if effusion persists

more than 1 monthmore than 1 month

�� Regular clinical and echocardiographic Regular clinical and echocardiographic

followfollow--up recommendedup recommended

�� Consider thoracic duct obstruction with Consider thoracic duct obstruction with

chylopericardium if persistentchylopericardium if persistent

�� Consider hypothyroidismConsider hypothyroidism



©2011 David Stultz

Pericardial HematomaPericardial Hematoma

��Blood clot in pericardial spaceBlood clot in pericardial space

��Causes tamponade physiologyCauses tamponade physiology

��Diagnosed by transthoracic or Diagnosed by transthoracic or transesophageal echocardiogramtransesophageal echocardiogram

�� EtiologyEtiology–– Iatrogenic Iatrogenic

��post cardiac surgery or other procedurepost cardiac surgery or other procedure

–– Aortic dissectionAortic dissection

–– TraumaTrauma

©2011 David Stultz

Case #2 TreatmentCase #2 Treatment

�� Thyroid studies normalThyroid studies normal

��Rheumatoid Factor, ANA negativeRheumatoid Factor, ANA negative

�� Erythrocyte Sedimentation rate 83Erythrocyte Sedimentation rate 83

�� Pericardiocentesis performedPericardiocentesis performed

–– Cytology negativeCytology negative

�� Treated with NSAIDSTreated with NSAIDS

��Diagnosis: idiopathic/viral Diagnosis: idiopathic/viral

pericarditispericarditis

©2011 David Stultz

What is the Most Common Cause of What is the Most Common Cause of

nonnon--Iatrogenic Cardiac Tamponade?Iatrogenic Cardiac Tamponade?

1.1. Idiopathic/ViralIdiopathic/Viral

2.2. MalignancyMalignancy

3.3. UremiaUremia

4.4. Acute Myocardial InfarctionAcute Myocardial Infarction

5.5. Autoimmune diseaseAutoimmune disease

6.6. TraumaTrauma

7.7. HypothyroidismHypothyroidism

©2011 David Stultz

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 (101°°F) 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, propafanone Levothyroxine 112 mcg/day, diltiazem 30 mg q12h, propafanone

150mg q12h, warfarin150mg q12h, warfarin

©2011 David Stultz

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, HDL Cholesterol 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

©2011 David Stultz

What is the Most Likely What is the Most Likely

Diagnosis?Diagnosis?

1.1. HypothyroidismHypothyroidism

2.2. Acute pericarditisAcute pericarditis

3.3. Pericardial tamponadePericardial tamponade

4.4. Restrictive cardiomyopathyRestrictive cardiomyopathy

5.5. Constrictive pericarditisConstrictive pericarditis

6.6. Ischemic cardiomyopathyIschemic cardiomyopathy

©2011 David Stultz

Constrictive PericarditisConstrictive Pericarditis

�� Symptoms of heart failure with Symptoms of heart failure with preserved 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 in Tuberculosis is major cause in developing countriesdeveloping countries



©2011 David Stultz

Constrictive Pericarditis vs. Constrictive Pericarditis vs.

Restrictive CardiomyopathyRestrictive Cardiomyopathy

��Restrictive Cardiomyopathy is RARERestrictive Cardiomyopathy is RARE

–– AmyloidosisAmyloidosis

–– SarcoidosisSarcoidosis

–– Hypereosinophilic syndromesHypereosinophilic syndromes

–– Endomyocardial fibrosisEndomyocardial fibrosis

–– Chemotherapy or RadiationChemotherapy or Radiation



©2011 David Stultz

Gross SpecimensGross Specimens

Constrictive pericarditis vs. Constrictive pericarditis vs.

Restrictive CardiomyopathyRestrictive Cardiomyopathy



©2011 David Stultz

Diagnosis of Constrictive Diagnosis of Constrictive

PericarditisPericarditis

��HistoryHistory

�� Physical examinationPhysical examination

–– Jugular venous distentionJugular venous distention

–– KussmaulKussmaul’’s sign (rise in JVD with s sign (rise in JVD with

inspiration)inspiration)

–– Pericardial knockPericardial knock

�� EKG EKG –– NonspecificNonspecific



©2011 David Stultz

Hemodynamics in a NutshellHemodynamics in a Nutshell

Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy

�� In Constrictive Pericarditis there is In Constrictive Pericarditis there is

ventricular interdependence accentuated ventricular interdependence accentuated

by respirationby respiration

–– As inspiration occurs, RV filling improves at As inspiration occurs, RV filling improves at

the expense of LV fillingthe expense of LV filling

–– RV pressure increases as LV pressure RV pressure increases as LV pressure

decreasesdecreases

�� Echocardiographic criteria based on this Echocardiographic criteria based on this

phenomenaphenomena

�� Can be measured invasivelyCan be measured invasively



©2011 David Stultz

Hemodynamics in a NutshellHemodynamics in a Nutshell

Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy



©2011 David Stultz

Treatment of Constrictive Treatment of Constrictive

PericarditisPericarditis

�� If transient due to acute If transient due to acute

inflammation, medical therapyinflammation, medical therapy

�� If chronic, pericardiectomy is If chronic, pericardiectomy is

consideredconsidered

–– Surgical mortality approaches 6%Surgical mortality approaches 6%

––Must be a complete pericardiectomyMust be a complete pericardiectomy



©2011 David Stultz

Case #3 TreatmentCase #3 Treatment

��Started on furosemideStarted on furosemide

�� Levothyroxine dose increasedLevothyroxine dose increased

��Referred to tertiary care center for Referred to tertiary care center for

pericardiectomypericardiectomy

©2011 David Stultz

EffusiveEffusive--Constrictive PericarditisConstrictive Pericarditis

��Both pericardial effusion and Both pericardial effusion and constrictive pericarditisconstrictive pericarditis

��Constrictive hemodynamics may Constrictive hemodynamics may persist after pericardiocentesispersist after pericardiocentesis

�� Initial treatment as pericarditisInitial treatment as pericarditis

��May be transient, resolve in 2May be transient, resolve in 2--3 3 monthsmonths

��May require pericardiectomy if May require pericardiectomy if symptoms persistsymptoms persist



©2011 David Stultz

Congenital Absence of Congenital Absence of

PericardiumPericardium

�� Usually partial absence of left Usually partial absence of left

pericardiumpericardium

�� Male predominanceMale predominance

�� Associated with Associated with

–– Atrial septal defectAtrial septal defect

–– Bicuspid aortic valveBicuspid aortic valve

–– Bronchogenic cystsBronchogenic cysts

�� Usually asymptomaticUsually asymptomatic

�� May require surgical closure of partial May 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


©2011 David Stultz

Chest XChest X--ray of Partially Absent Pericardiumray of Partially Absent Pericardium

http://www.bcm.edu/radiology/cases/pediatric/text/7d-desc.htm

©2011 David Stultz

Pericardial CystPericardial Cyst

�� BenignBenign

�� Incidental mass on CT or Chest XIncidental mass on CT or Chest X--rayray

�� Usually located at right costophrenic Usually located at right costophrenic

angleangle

�� Echocardiography, cardiac CT, or cardiac Echocardiography, cardiac CT, or cardiac

MRI can differentiateMRI can differentiate

–– MalignancyMalignancy

–– Diaphragmatic herniaDiaphragmatic hernia

–– Cardiac chamber enlargementCardiac chamber enlargement

�� No treatment necessary if asymptomaticNo treatment necessary if asymptomaticKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and


©2011 David Stultz

http://radiopaedia.org/encyclopaedia/quizzes/all/11753

http://www.ctsnet.org/sections/clinicalresources/clinicalcases/article-16.html

©2011 David Stultz

©2011 David Stultz

ConclusionsConclusions

�� 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 of thickened pericardium, and history of

pericarditis or radiation exposurepericarditis or radiation exposure

©2011 David Stultz Pericardial Diseases

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