Pericardial Disease: Difference between revisions

The pericardium comprises two layers; the visceral layer that adheres to epicardial surface of the heart, and the parietal layer that surrounds most of the heart. Pericardial disease is common, and diagnosis is usually straightforward as the pericardium reacts to disruption by a wide variety of agents and processes in a relatively uniform manner. Typical presentation is with chest pain and fever, production of pericardial fluid with possible cardiac tamponade, or a constrictive pattern by thickening, retraction and calcification.  

An increase in intrapericardial pressure, resulting in compression of the heart, and thereby a resitriction of cardiac inflow, is termed cardiac tamponade. Tamponade may result from pericardial effusion of any cause. The intrapericardial pressure importantly determines to what extent cardiac inflow is decreased, but two factors need to be taken into consideration. First, intrapericardial pressure is determined not only on the amount of fluid that accumulates, but also on the rate with which this accumulation proceeds, and the available distensibility of the pericardium. Chronic effusions may therefore lead to small increases in intrapericardial pressures in the presence of large fluid accumulations, and small accumulations may directly lead to severe cardiac tamponade for example after free wall rupture. Second, the intravascular volume and intra-atrial, and -ventricular pressures determine at what pressure inflow becomes impaired. When intrapericardial pressure exceeds right atrial pressure (approximately 8 mmHg), tamponade typically follows. However, in patients in whom intra-atrial pressure is decreased, for example due to volume depletion, tamponade may already occur at lower intrapericardial pressures; low-pressure cardiac tamponade.

When secondary to inflammatory pericarditis, tamponade up to moderate severity may be treated by anti-inflammatory drugs. In severe tamponade, pericardiocentesis should be performed to immediately alleviate intrapericardial pressure. Surgical drainage should be considered when pericardiocentesis is unsuccessful, or when tamponade recurs.

Acute inflammation of the pericardium may result from a wide variety of etiologies (Table 1), and typically presents with chest pain, a pericardial friction rub on auscultation, and repolarization changes on the electrocardiogram.