Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.     

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.     

MR imaging of the pericardium

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.     

A review of pericardial diseases: clinical, ECG and hemodynamic features and management

Pericardial diseases are common, have multiple causes, and are often misdiagnosed. Physicians need to recognize the characteristic and distinguishing features of the three most important pericardial conditions: acute pericarditis, cardiac tamponade, and constrictive pericarditis. In these conditions, proper diagnosis and appropriate management can significantly reduce morbidity and mortality.     

CT Imaging of the Pericardium

Pericardial disease can be challenging to diagnose, and imaging can play a useful role in confirming or even suggesting the diagnosis. Computed tomography (CT) is a particularly appealing option for investigating pericardial disease in many patients because the differential diagnosis for symptoms of acute pericarditis or constrictive pericarditis often includes other diseases which are also well assessed with CT. In addition, many patients will have findings of pericardial disease manifest on CT imaging for other suspected diseases, and these findings can be missed if careful attention is not paid to the pericardium. CT also can play an important role in evaluating specific pericardial lesions, such as cysts, tumors, and abscesses. We will review findings of various pericardial diseases on CT with illustrative cases.     

Purulent pericarditis misdiagnosed as septic shock

BACKGROUND: Septic shock is common, with approximately 200,000 cases recognized annually. This syndrome is so well characterized that when a patient is febrile and in shock, septic shock may be diagnosed without regard to alternative possibilities. Purulent pericarditis is a relatively rare disorder in which fever and hypotension are common. Classic signs and symptoms, such as chest pain, pericardial friction rub, pulsus paradoxus, and elevation of jugular venous pressure, are seen in only 50%. METHODS: In this report, we describe four patients in whom purulent pericarditis and pericardial tamponade was initially misdiagnosed as septic shock. During a 3-month period, three men and one woman (mean age, 44.5 years) came to Kern Medical Center with purulent pericarditis and pericardial tamponade. These cases represented 13% of patients admitted with a diagnosis of septic shock. RESULTS: All patients were bacteremic, and the classic findings of pericardial tamponade were absent or relatively subtle. Hemodynamic findings of elevated systemic vascular resistance, low cardiac output, and normal pulmonary artery occlusion pressure were critical to the diagnosis. CONCLUSIONS: Consideration of purulent pericarditis is important in cases diagnosed as septic shock. Clinicians should be aware that patients with purulent pericarditis may not exhibit classic signs and symptoms, and a high index of suspicion is necessary for appropriate management.     

Pericardial Disease: Diagnosis and Management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.CMR = cardiac magnetic resonance imaging; CT = computed tomography; CYP = cytochrome P450; ECG = electrocardiographic; ESC = European Society of Cardiology; IVC = inferior vena cava; LV = left ventricular; NSAID = nonsteroidal anti-inflammatory drug; RA = right atrium; RV = right ventricleThe pericardium is a thin covering that separates the heart from the remaining mediastinal structures and provides structural support while also having a substantial hemodynamic impact on the heart. The pericardium is not essential—normal cardiac function can be maintained in its absence—however, diseased pericardium presenting clinically as acute or chronic recurrent pericarditis, pericardial effusion, cardiac tamponade, and pericardial constriction can be challenging to manage and life-threatening in some cases. The etiology of pericardial disease is often difficult to determine or remains idiopathic. However, microorganisms, including viruses and bacteria; systemic illnesses, including neoplasia, autoimmune disease, and connective tissue disease; renal failure; previous cardiac surgery; previous myocardial infarction; trauma; aortic dissection; radiation; and, rarely, drugs have been associated with pericardial diseases.The diagnosis and management of pericardial diseases remain challenging because of the vast spectrum of manifestations and the lack of clinical data on which to base guidelines by the American College of Cardiology and the American Heart Association. However, the European Society of Cardiology (ESC) published guidelines on pericardial disease in 2004.¹ This review aims to describe the methods of diagnosing and managing major pericardial syndromes on the basis of the literature and the clinical experience of our pericardial clinic. Searches were performed on PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. No date limitations were set. Studies were selected on the basis of clinical relevance and the impact on clinical practice.     

Acute pericarditis

Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.     

Multimodality imaging for the diagnosis and treatment of constrictive pericarditis

ABSTRACT

Introduction: Constrictive pericarditis can result in debilitating congestive right heart failure and has been considered an important cause of morbidity and mortality in patients with cardiovascular disease. Multimodality imaging continues to play a fundamental role in the individual approach to diagnosis, management, and prognosis of patients with this clinical syndrome.

Areas covered: This article gives an overview of the clinical spectrum of constrictive pericardial diseases and the role of multimodality imaging in the diagnosis of constrictive pericarditis. There is a focus on the emerging role of cardiac magnetic resonance (CMR) for the diagnosis, management, and prognostication of patients with constrictive pericarditis based on more recent case series, retrospective and prospective studies, which have helped to define the role of CMR.

Expert opinion: Advanced multimodality imaging assists with identification of both overt and subclinical pericardial inflammation. This allows the pericardiologist to recognize patients with potentially reversible disease, trial medical therapy, and thereby avoid mechanical removal of the pericardium. Further, pericardial characterization by CMR has provided novel information about the natural history of these pericardial conditions, which can help tailor therapy and improve prognosis.     

Treatment of recurrent pericarditis

Recurrent pericarditis is the most common and troublesome complication of pericarditis affecting around a third of patients. Treatment of this condition is often one of the most challenging task in pericardial diseases management, especially in corticosteroids-dependent cases. The aim of this review is to report current knowledge on the treatment, prevention and prognosis of this disease, with a special focus on more recently published contributions during the last 5 years.     

Hypothyroidism presenting as acute cardiac tamponade with viral pericarditis

This report describes the case of a young woman who presented to an emergency department with severe abdominal pain and shock. The patient was found to have pericardial tamponade due to a massive pericardial effusion. On further evaluation, the etiology of this effusion was considered to be secondary to hypothyroidism with concominant acute viral pericarditis leading to a fulminant tamponade. The presentation, differential diagnosis, and management of pericardial effusion and tamponade secondary to hypothyroidism and viral pericarditis are discussed. The diagnosis of hypothyroidism in conjunction with acute viral pericarditis should be considered in patients presenting with unexplained pericardial effusion and tamponade.     

Cardiac tamponade in systemic lupus erythematosus: an unusual initial manifestation

I have described a patient in whom cardiac tamponade occurred as the initial clinical manifestation of SLE. Although pericarditis is a common clinical entity in SLE, cardiac tamponade with this disease is rare. If suspected, the diagnosis can be made by the proper selection of tests of serum and pericardial fluid, which should include the search for pericardial LE cells. This report emphasizes the importance of screening for connective tissue disease in patients with pericarditis.     

Evaluation and management of pericarditis

Pericarditis may be caused by infectious or noninfectious noxa. Most cases are labeled as 'idiopathic' because the traditional diagnostic approach often fails to identify the etiology. Most important causes are presumed to be viruses in countries with a low prevalence of tuberculosis and tuberculosis in developing countries. Noninfectious pericarditis mainly includes autoimmune systemic diseases, post-pericardiotomy syndromes and neoplastic pericardial disease. Treatment should be targeted to the cause, but remains empirical with NSAIDs and the possible adjunct of colchicine in idiopathic cases. Corticosteroids use should be limited to patients with NSAID contraindications/intolerance or failure, and rarely for specific conditions (i.e., pregnancy and systemic autoimmune diseases). Recurrences are the most common complication, but the overall prognosis is related to the etiology, usually benign in idiopathic pericarditis.     

CUPS to Manage Pericarditis

Pericarditis is the most encountered pericardial disease in acute clinical settings. It is essential that medical professionals have a thorough understanding of the various therapies and implications involved in managing pericarditis. This report provides a brief review on the classifications and diagnosis of pericarditis and presents a mnemonic that can be used as a clinical decision-making tool to guide nurse practitioners in the management of pericarditis.     

Evaluation and management of pericarditis

Pericarditis may be caused by infectious or noninfectious noxa. Most cases are labeled as ‘idiopathic’ because the traditional diagnostic approach often fails to identify the etiology. Most important causes are presumed to be viruses in countries with a low prevalence of tuberculosis and tuberculosis in developing countries. Noninfectious pericarditis mainly includes autoimmune systemic diseases, post-pericardiotomy syndromes and neoplastic pericardial disease. Treatment should be targeted to the cause, but remains empirical with NSAIDs and the possible adjunct of colchicine in idiopathic cases. Corticosteroids use should be limited to patients with NSAID contraindications/intolerance or failure, and rarely for specific conditions (i.e., pregnancy and systemic autoimmune diseases). Recurrences are the most common complication, but the overall prognosis is related to the etiology, usually benign in idiopathic pericarditis.     

Diagnostic issues in the clinical management of pericarditis

Aims: To review the current major diagnostic issues on the diagnosis of acute and recurrent pericarditis. Methods: To review the current available evidence, we performed a through search of several evidence‐based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence‐based guidelines from National Guidelines Clearinghouse and a comprehensive Medline search with the MeSH terms ‘pericarditis’, ‘etiology’ and ‘diagnosis’. Results: The diagnosis of pericarditis is based on clinical criteria including symptoms, presence of specific physical findings (rubs), electrocardiographical changes and pericardial effusion. Although the aetiology may be varied, most cases are idiopathic or viral, even after an extensive diagnostic evaluation. In such cases, the course is often benign following anti‐inflammatory treatment, and management would be not affected by a more precise diagnostic evaluation. A triage of pericarditis can be safely performed on the basis of the clinical and echocardiographical presentation. Specific diagnostic tests are not warranted if no specific aetiologies are suspected on the basis of the epidemiological background, history and presentation. High‐risk features associated with specific aetiologies or complications include: fever > 38 °C, subacute onset, large pericardial effusion, cardiac tamponade, lack of response to aspirin or a NSAID. Conclusions: A targeted diagnostic evaluation is warranted in acute and recurrent pericarditis, with a specific aetiological search to rule out tuberculous, purulent or neoplastic pericarditis, as well as pericarditis related to a systemic disease, in selected patients according to the epidemiological background, presentation and clinical suspicion.     

Pericardial disease: a clinical review

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.     

Pericarditis, pericardial effusion, cardiac tamponade, and constriction

Critical care aspects of pericardial disease are covered, including diagnosis and differential diagnosis of acute pericarditis, pericardial effusion with and without cardiac tamponade, constrictive pericarditis and effusive-constrictive pericarditis. Emphasis is placed on clinical signs and the important invasive and noninvasive diagnostic procedures, particularly various imaging methods (emphasis on echocardiography), electrocardiography, and cardiac catheterization. Medical and surgical therapies are reviewed, and the technique of pericardiocentesis is presented.     

Cardiac tamponade as a manifestation of tuberculosis

Tuberculosis has been increasing in incidence in recent years. Pericardial involvement and pericardial effusions are well-documented and may result in pericardial tamponade. Despite this, large pericardial effusions are uncommon, and manifestation as cardiac tamponade is rare. We report two cases of tuberculous pericarditis in which the initial feature was tamponade. Since the diagnosis of tuberculosis may be delayed due to the slow-growing nature of the bacterium, physicians need to be aware of this possibility and consider the use of modern diagnostic techniques that may permit an earlier diagnosis.     

The constricted heart

Often indistinguishable from restrictive cardiomyopathy and hepatic cirrohis, clinical acumen is essential in the recognition and diagnosis of constrictive pericarditis. A thorough medical history should rule out infectious disease exposure. A physical examination may include variable signs such as Kussmaul's sign, pulsus paradoxus, and pericardial knock, while jugular venous distention is of cardinal significance in eliminating liver cirrhosis as the cause of ascites. A complete physical examination, appropriate imaging studies, and cardiac catheterizaiton are crucial for proper diagnosis and prompt treatment of constrictive pericarditis.