PERICARDIAL DISEASE

The normal pericardium is a fibroelastic sac containing a thin layer of fluid (50 mL) that surrounds the heart and roots of the great vessels.

Acute pericarditis

Aetiology

In the UK, acute inflammation of the pericardium is most commonly due to viral infection (Coxsackie B, echovirus, HIV infection) or follows myocardial infarction. Other causes include uraemia, autoimmune rheumatic diseases, trauma, infection (bacterial, tuberculosis, fungal), and malignancy (breast, lung, leukaemia and lymphoma).

Clinical features

There is sharp retrosternal chest pain which is characteristically relieved by leaning forward. Pain may be worse on inspiration and radiate to the neck and shoulders. The Cardinal clinical sign is a pericardial friction rub, which may be transient.

Diagnosis

The ECG is diagnostic. There is concave upwards (saddle shaped) ST segment elevation across all leads and return towards baseline as inflammation sub-sides. ST segment elevation is convex upwards in myocardial infarction and limited to the leads that face the infarct.

Management

Treatment is of the underlying disorder plus NSAIDs. Systemic corticosteroids are used in resistant cases. NSAIDs should not be used in the few days fol-lowing myocardial infarction as they are associated with a higher rate of myocardial rupture. Complications of acute pericarditis are pericardial effu-sion and chronic pericarditis (>6-12 months).

Pericardial effusion and tamponade

Pericardial effusion is an accumulation of fluid in the pericardial sac which may result from any of the causes of pericarditis. Hypothyroidism also causes a pericardial effusion which rarely compromises ventricular function. Pericardial tamponade is a medical emergency and occurs when a large amount of pericardial fluid (which has often accumulated rapidly) restricts diastolic ventricular filling and causes a marked reduction in cardiac output.

Clinical features

The effusion obscures the apex beat and the heart sounds are soft. The signs of pericardial tamponade are hypotension, tachycardia and an elevated jugular venous pressure, which paradoxically rises with inspiration (Kuss-maul's sign). There is invariably pulsus paradoxus (a fall in blood pressure of more than 10 mmHg on inspiration). This is the result of increased venous return to the right side of the heart during inspiration. The increased right ventricular volume thus occupies more space within the rigid pericardium and impairs left ventricular filling.

Investigations

■ Chest X-ray shows a large globular heart.

■ ECG shows low-voltage complexes.

■ Echocardiography is diagnostic, showing an echo-free space around the heart.

■ Invasive tests to establish the cause of the effusion may only be neces-sary with a persistent effusion, if a purulent or tuberculous effusion is suspected, or if the eftusion is not known to be secondary to an underly-ing illness. Pericardiocentesis (aspiration of fluid under echocardiographic guidance) and pericardial biopsy for culture, cytology/histology and PCR (for tuberculosis) give a greater diagnostic yield with large effusions.

Management

The treatment of tamponade is emergency pericardiocentesis. Pericardial fluid is drained percutaneously by introducing a needle into the pericardial sac. If the effusion recurs, in spite of treatment of the underlying cause, excision of a pericardial segment may be necessary. Fluid is then absorbed through the pleural and mediastinal lymphatics.

Constrictive pericarditis

In the UK, most cases of constrictive pericarditis are idiopathic in origin or result from intrapericardial haemorrhage during heart surgery.

Clinical features

The heart becomes encased within a rigid fibrotic peri-cardial sac which prevents adequate diastolic filling of the ventricles. The clinical features resemble those of right-sided heart failure, with jugular venous distension, dependent oedema, hepatomegaly and ascites. Kussmaul's sign (JVP rises paradoxically with inspiration) is usually present and there may be pulsus paradoxus, atrial fibrillation and, on auscultation, a pericardial knock caused by rapid ventricular filling. Clinically, constrictive pericarditis cannot be dis-tinguished from restrictive cardiomyopathy (p. 478).

Investigations

A chest X-ray shows a normal heart size and pericardial calcification (best seen on the lateral film). Diagnosis is made by CT or MRI, which shows pericardial thickening and calcification.

Management

Treatment is by surgical excision of the pericardium.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
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6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

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Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

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COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
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EPILEPSY AND LOSS OF CONSCIOUSNESS
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HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
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Dermatology

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