Pericarditis
The pericardium is the fibroserous sac that envelops, supports, and protects the heart. Inflammation of this sac is called pericarditis.
This condition occurs in acute and chronic forms. The acute form can be fibrinous or effusive, with serous, purulent, or hemorrhagic exudate. The chronic form (called constrictive pericarditis) is characterized by dense, fibrous pericardial thickening.
The prognosis depends on the underlying cause but typically is good in acute pericarditis unless constriction occurs.
Causes
Common causes of this disorder include:
bacterial, fungal, or viral infection (infectious pericarditis)
neoplasms (primary or metastatic from lungs, breasts, or other organs)
high-dose radiation to the chest
uremia
hypersensitivity or autoimmune disease, such as acute rheumatic fever (the most common cause of pericarditis in children), systemic lupus erythematosus, and rheumatoid arthritis
drugs, such as hydralazine or procainamide
idiopathic factors (most common in acute pericarditis)
postcardiac injury, such as myocardial infarction (which later causes an autoimmune reaction known as Dressler’s syndrome in the pericardium) and trauma and surgery that leave the pericardium intact but allow blood to leak into the pericardial cavity.
Less common causes of pericarditis include aortic aneurysm with pericardial leakage as well as myxedema with cholesterol deposits in the pericardium.
Complications
Pericardial effusion is the major complication of acute pericarditis. If fluid accumulates rapidly, cardiac tamponade may occur, resulting in shock, cardiovascular collapse, and eventually death.
Assessment
The patient’s history may include an event or disease that can cause pericarditis, such as chest trauma, myocardial infarction, or recent bacterial infection.
The patient with acute pericarditis typically complains of sharp, sudden pain, usually starting over the sternum and radiating to the neck, shoulders, back, and arms. The pain is usually pleuritic, increasing with deep inspiration and decreasing when the patient sits up and leans forward. This decrease occurs because leaning forward pulls the heart away from the diaphragmatic pleurae of the lungs. The patient may complain of dyspnea.
Pericarditis can mimic the pain of myocardial infarction. However, the patient may have no pain if he has slowly developing tuberculous pericarditis or postirradiation, neoplastic, or uremic pericarditis.
Auscultation almost always reveals a pericardial friction rub, which is a grating sound heard as the heart moves. You can hear it best during forced expiration, while the patient leans forward or is on his hands and knees in bed. The rub may have up to three components that correspond
to atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole.
to atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole.
Occasionally, the friction rub is heard only briefly or not at all. If acute pericarditis has caused very large pericardial effusions, heart sounds may be distant.
Palpation may reveal a diminished or an absent apical impulse.
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