Pericardial Disease: Selected Highlights

Residents’ Noon Conference11/12/2009

Pericardial disease: Differential Diagnosis InfectionsA. Viral - Coxsackievirus, Echovirus, Adenovirus, EBV, CMV,

Influenza, Varicella, Rubella, HIV, Hepatitis B, Mumps, Parvovirus B19, Vaccina (smallpox vaccination)

B. Bacterial - Staphylococcus, Streptococcus, Pneumococcus, Haemophilus, Neisseria (gonorrhoeae or meningitidis), Chlamydia (psittaci or trachomatis), Legionella, Tuberculosis, Salmonella, Lyme disease

C. Mycoplasma D. Fungal - Histoplasmosis, Aspergillosis, Blastomycosis,

Coccidiodomycosis, Actinomycosis, Nocardia, Candida E. Parasitic - Echinococcus, amebiasis, Toxoplasmosis F. Infective endocarditis with valve ring abscess (the first of five slides)

Pericardial disease: Differential Diagnosis, cont. Radiation NeoplasmA. Metastatic - Lung or breast cancer, Hodgkin's disease,

leukemia, melanoma B. Primary - rhabdomyosarcoma, teratoma, thymoma, fibroma,

lipoma, leiomyoma, angioma C. Paraneoplastic CardiacA. Early infarction pericarditis B. Late postcardiac injury syndrome (Dressler's syndrome), also

seen in other settings C. MyocarditisD. Dissecting aortic aneurysm(continued on next slide)

Pericardial disease: Differential Diagnosis, cont. DrugsA. Procainamide, isoniazid, or hydralazine as part of drug-

induced lupusB. Other - cromolyn sodium, dantrolene, methysergide,

anticoagulants, thrombolytics, phenytoin, penicillin, phenylbutazone, doxorubicin

MetabolicA. Hypothyroidism - primarily pericardial effusionB. UremiaC. Ovarian hyperstimulation syndrome(continued on next slide)

Pericardial disease: Differential Diagnosis, cont. TraumaA. Blunt B. Penetrating C. Iatrogenic - Catheter and pacemaker perforations,

cardiopulmonary resuscitation, post-thoracic surgery AutoimmuneA. Rheumatic diseases - including lupus, rheumatoid arthritis,

vasculitis, scleroderma, mixed connective diseaseB. Other - Wegener's granulomatosis, polyarteritis nodosa,

sarcoidosis, inflammatory bowel disease (Crohn's, ulcerative colitis), Whipple's, giant cell arteritis, Behcet's disease

(continued on next slide)

Pericardial disease: Differential Diagnosis, cont. IdiopathicIn most case series, the majority of patients are not found to

have an identifiable cause of pericardial disease. Frequently such cases are presumed to have a viral or autoimmune etiology.

Adapted from Shabetai, R. Diseases of the pericardium. In: Hurst's The Heart, 8th ed, Schlant, RC, Alexander, RW, et al (Eds).

Pulsus Paradoxus Exam How to perform and interpret the

pulsus paradoxus examination The most important learning goal of

this conference

Is Pulsus Present?

Decrease in systolic BP of 12mmHg or more

Pulsus Paradoxus: Checklist Make sure the heart rhythm is

regular Make sure respiration is quiet Prepare the patient: Explain that the

BP cuff will be inflated longer than usual

Do not attempt to assess patient’s respiration--focus on the BP cuff

Pulsus Paradoxus Exam Inflate cuff until no Korotkoff sounds

audible Deflate cuff to determine the highest

pressure where any Korotkoff sounds are audible-This is the maximum possible systolic blood pressure

NEJM paradoxus tracing

Pulsus Paradoxus, cont. Deflate cuff to the highest pressure

where Korotkoff sounds are audible with EVERY heart beat

Subtract the maximal possible systolic BP from this number--this is the pulsus paradoxus

Document all the numbers in the electronic medical record

Pulsus paradoxus

What is the sensitivity and specificity of a pulsus paradoxus greater than 10mmHg in detecting pericardial tamponade?

What about 12mmHg?

(assuming that the patient has known pericardial effusion, a regular heart rate, and is being examined during quiet respiration)

Pulsus paradoxus, cont.

Pulsus paradoxus >12mmHg has a sensitivity of 98% and specificity of 85% to detect tamponade.

Choosing a cutoff of 10mmHg worsens specificity without changing sensitivity significantly (most tamponade patients have pulsus > 20mmHg)

Curtiss EI et. al. Pulsus Paradoxus: Definition and Relation to the Severity of Tamponade. An Heart J 115:391-398, 1998. Tamponade was defined as an improvement in cardiac output of 20% or more following pericardiocentesis.

Differential Diagnosis of Pulsus without Tamponade:

Constrictive pericarditis Asthma exacerbation (severe) COPD exacerbation Pregnancy/obesity Right ventricular infarction SVC syndrome Pulmonary embolism (rare) Atrioventricular dissociation

Severe Acute Asthma: Pulsus Without Tamponade Low sensitivity but high specificity

finding for severe asthma Severe: FEV1/FVC < 50%,

FEV1 < 1L, peak flow < 200/min, and peak flow < 30% predicted

(A peak flow meter is usually more useful in the clinical setting)

Severe Asthma: Pulsus Without Tamponade

Pulsus severity

Sensitivity %

Specificity %

Positive LR

Negative LR

>10mmHg 52-68 69-92 2.7 0.5

>20mmHg 19-39 92-100 8.2 0.8

>25mmHg 16 99 22.6 0.8

McGee, Steven. Evidence-Based Physical Diagnosis.

Philadelphia: Elsevier, 2001.

What is the paradox? Finding first described

in 1873 Sphygmomanometer

invented 1881

Adolph Kussmaul

1822-1902

Malignant Thymoma, RV failure, Pericardial Tamponade

CXR