1. DISEASES OF THE PERICARDIUM
1-ACUTE PERICARDITIS
2-PERICADIAL EFFUSION (AND CARDIAC TAMPONADE)
3-CONSTRICTIVE PERICARDITIS

2. THE PERICARDIUM Structure and function Functions
Protective sac around heart,
two distinct layers
outer fibrous pareital &
inner visceral
Contains == 50 ml of fluid
similar to lymph-
lubricates surface of heart.
Functions
1- limits distension of heart
2- haemodynamic interdependence of ventricles
3-barrier to infection.

3. 1-ACUTE PERICARDITIS Inflammation of visceral and parietal layers
AETIOLOGY
infection,
immunological reaction,
trauma
neoplasm
unexplained.
Pericarditis and myocarditis often coexist,
1-Common causes
1-Viral (e.g. Coxsackie B, but often not identified)
2-Acute myocardial infarction
2- Less common Rare (in UK)
Uraemia Bacterial infection
Malignant disease Rheumatic fever
Trauma (e.g. blunt chest injury) Tuberculosis
Connective tissue disease (e.g. SLE)

4. Pathological types 1-fibrinous 2-serous 3-haemorrhagic 4-purulent.
1- fibrinous exudate 
varying degrees of adhesion formation,
2- serous pericarditis 
large effusion - turbid, straw-coloured fluid +high protein content.
3- haemorrhagic effusion =
malignant disease, part. Ca. breast, ca. bronchus and lymphoma.
4-Purulent = rare
complication of septicaemia
direct spread -- intrathoracic infection / penetrating injury

5. Clinical features TRIAD =Chest pain +fever+ Pericardial rub
Retrosternal,
Radiates to shoulders and neck
Aggravated by
deep breathing,
movement
change of position
exercise
swallowing.
2- fever- low-grade
3- pericardial friction rub- diagnostic
high-pitched
superficial scratching or crunching noise
produced by movement of inflamed pericardium,
usually heard in systole but may also be audible in diastole
frequently has a 'to-and-fro' quality.

6. Investigations ECG Chest x-ray and echocardiography 
ST elevation -upward concavity( over affected area)- widespread.
PR interval depression – very sensitive indicator of acute pericarditis.
T-wave inversion,(Later) esp. if there is a degree of myocarditis
Chest x-ray and echocardiography 
normal in most cases (unless complicated by effusion)

8. Treatment Pain = aspirin (600 mg 4-hourly) Outcome
indometacin (25 mg 8-hr.). more potent anti-inflammatory
Corticosteroids may suppress symptoms –
no evidence that they accelerate cure.
Outcome
1- viral pericarditis=
recovery usually occurs within few days or weeks,
----recurrences (chronic relapsing pericarditis).
2-Purulent pericarditis
antimicrobial therapy,
paracentesis
if necessary, surgical drainage.

9. 2-PERICARDIAL EFFUSION
Abnormal accumulation of
fluid within pericardial space
TYPES
Small=
hemodynamically insignificant effusion  generally asymptomatic
Large 
chest pressure or symptoms related to compression of adjacent structures
Hemodynamic consequences of PE 
rate of fluid accumulation rather than size
slowlymay accommodate up to 2 liters without P.pressure
rapid ml. may result in cardiac tamponade

10. Clinical Features difficult to detect clinically;
1- sensation of retrosternal oppression.
2-apical impulse ----difficult to palpate
3-heart sounds --- quieter,
4- pericardial friction- ( not always abolished).

11. INVESTIGATIONS
ECG
CXR
Echocardiography
CT & MRI- detect the cause

12. ECG: QRS voltages - reduced in presence of large effusion
ECG: QRS voltages - reduced in presence of large effusion. QRS complexes - alternate in amplitude { to-and-fro motion of heart within fluid-filled pericardial sac }(electrical alternans).

13. Radiologically: Serial chest X-rays = rapid increase in size of cardiac shadow over days or even hours, large effusion = heart often has globular or pear-shaped appearance

14. Echocardiography definitive investigation for detection ,size ,location and H-D significance

15. CT and MRI detect the cause

16. Cardiac tamponade Aetiology
collection of fluid or blood in the pericardial sac, compressing the heart
effusion may be small and is very occasionally less than 100 mL.
=acute heart failure due to compression of heart by a large or rapidly developing effusion
Typical physical findings =markedly raised JVP,hypotension,pulsus paradoxus and oliguria.
Atypical presentations =effusion is loculated (result of previous pericarditis or cardiac surgery.)
Sudden deterioration may be due to bleeding into the pericardial space.
Aetiology
complication of pericarditis
malignant disease.
trauma
rupture of t free wall of the myocardium following MI.

17. Clinical features of pericardial tamponade
Dyspnoea
Collapse
Tachycardia
Hypotension
Gross elevation of the JVP
Soft heart sounds with an early third heart sound
Pulsus paradoxus (a large fall in BP during inspiration, when the pulse may be impalpable)
Kussmaul’s sign (paradoxical rise in JVP during inspiration

18. - ECG features of underlying disease, e.g.pericarditis or acute MI.
large pericardial effusion=ECG complexes are small
electrical alternans: changing axis with alternate beats caused by t heart swinging from side to side in the pericardial fluid.
Chest X-ray
enlarged globular heart but can look normal.
Echocardiography –
confirming t diagnosis
identify the optimum site for aspiration of the fluid.
Prompt recognition of tamponade is important because the patient usually responds dramatically to percutaneous pericardiocentesis or surgical drainage

19. Cardiac Tamponade
Compression heart by a large or rapidly developing effusion
acute heart failure

20. Pericardial aspiration
Indicated for
diagnostic purposes or
treatment of cardiac tamponade.
Accomplished by
introducing needle just medial to cardiac apex or
by inserting a needle below the xiphoid process + simultaneous echo.
Amount
few millilitres of fluid -sufficient for diagnostic purposes;
therapeutic drainage - a plastic cannula inserted over a needle or guidewire.
Complications of pericardiocentesis=
arrhythmias
damage to coronary artery
bleeding with exacerbation of tamponade - injury to the right ventricle.
When tamponade due to cardiac rupture or aortic dissection
P. aspiration may precipitate further bleeding == emergency surgery

21. TUBERCULOUS PERICARDITIS
1-Complicatiion pulmonary tuberculosis /first manifestation
2-In Africa, a tuberculous PE is a common feature of AIDS.
Clinical features-
1-chronic malaise,
2-weight loss
3-low-grade fever.
OUTCOME
An effusion usually develops  tamponade.
pericardium may become thick and unyielding pericardial constriction
( An associated pleural effusion is often present).
Diagnosis –
aspiration of the fluid and direct examination or culture for tubercle bacilli.
Treatment-
Antituberculous chemotherapy + 3-M course of prednisolone (initial dose 60 mg a day, tapering down rapidly =improve outcome.

22. 3-CHRONIC CONSTRICTIVE PERICARDITIS
progressive thickening, fibrosis and calcification =pericardium.
Heart = encased in a solid shell and cannot fill properly;
calcification may extend into the myocardium- impaired myocardial contraction
Atiology
often follows an attack of tuberculous pericarditis
Complication of
haemopericardium
viral pericarditis
rheumatoid arthritis
purulent pericarditis.

23. - Clinical features symptoms and signs of systemic venous congestion
atrial fibrillation = common
dramatic ascites and hepatomegaly.
Breathlessness is not prominent symptom ( lungs seldom congested.)
suspected - unexplained right heart failure and a small heart.
Fatigue
Rapid, low-volume pulse
Elevated JVP with a rapid y descent
Kussmaul's sign (a paradoxical rise in the JVP during inspiration)
Loud early third heart sound or 'pericardial knock'
Hepatomegaly
Ascites
Peripheral oedema
Pulsus paradoxus ( excessive fall in BP during inspiration in some cases

24. chest X-ray=show pericardial calcification),
Investigations
chest X-ray=show pericardial calcification),
echocardiography = establish the diagnosis.
CT and MRI = useful techniques for imaging the pericardium.
Differential diagnosis
often difficult to distinguish from restrictive cardiomyopathy
final diagnosis may depend on complex echo-Doppler studies and cardiac catheterisation.

28. Management Surgical resection of the diseased pericardium =
dramatic improvement
carries a high morbidity 
disappointing results in up to 50% of patients