PERICARDITIS

Jake Marais, MD UNC Hospitals Internal Medicine 1/12/07

TB Pericarditis

Epidemiology
Incidence low secondary to low incidence of TB in general Occurs in 1-2% of patients with pulmonary TB One Spanish study found 4.4% of pulmonary TB patient s had pericarditis Keep in mind that Spanish (and South African) figures on incidence far exceed that in the USA A Mayo clinic study found 2% cases of pericarditis in pulmonary TB patients as apposed to a similar study at Mayo fifty years ago However, parts of the USA have high immigrant populations where TB pericarditis rates are much higher, as established at Baylor in 1990.

Pathogenesis
TB pericarditis is usually associated with TB somewhere else in body Usually represent reactivation disease thus a primary infective location usually not found 4 Stages

Do not necessarily occur in order or individually

Dry

Inflammatory process thought secondary to hypersensitivity reaction to tuberculoprotein

Effusive

Serosangiouness fluid with leukocytes and high protein and tubercle bacilli found in low concentration Pressures consistent with cardiac tamponade are found

Pathogenesis
Absorptive

50% of patients will reabsorb this fluid without treatment Healing with fibrosis and calcification and overall thickening of visceral pericardium Pressures consistent with constrictive pericarditis are found Patients who have continued elevation of pressures after pericardiocentesis have effusive-constrictive pericarditis

Constrictive

Restrictive Cardiomyopathy
nondilated rigid ventricle severe diastolic dysfunction and restrictive filling History of infiltrative disease

amyloidosis sarcoidosis

bundle branch block, ventricular hypertrophy, pathologic Q waves, or impaired atrioventricular conduction strongly favors restrictive cardiomyopathy Decreased myocardial tissue velocity by doppler Pro-BNP elevated Independent Ventricular action 2/2 stiff myocardium and septum

ie: no pulsus paradoxus

Tissue Doppler:
Myocardial velocity is shown by arrows in row C.

Constrictive Pericarditis
scarring with the consequent loss of elasticity of the pericardial sac impairment of ventricular filling affecting all four cardiac chambers Equalization of pressures in severe constriction Inspiratory decrease in Mitral E velocity

Constrictive Pericarditis
majority of ventricular filling occurs rapidly in early diastole ie: rapid and deep Y descent on RA tracings.

Constrictive Pericarditis
Suggested by history prior pericarditis Tuberculosis connective tissue disease Malignancy Trauma cardiac surgery Pro-BNP normal as myocardium not stretched Thickened pericardium on Chest CT or calcification on CXR

Constrictive Pericarditis
Pericardial Calcification on CXR

Cardiac Tamponade
Pericardial fluid enlarging around the heart Acute vs Subacute Equalization of pressures measured by catheterization

RA = RVED = PCW = Pericardial

Blunting of y descent

As opposed to exaggerated y descent in constrictive pericarditis

Clinical Manifestations
Cough Dyspnea Chest pain Night sweats Orthopnea Weight loss

Physical Exam
Fever Tachycardia hypotension increased JVD

Kussmauls Sign
Loss of the expected inspiratory decline of jugular venous pressure Also seen in right heart failure and severe venous congestion Seen in tamponade and constrictive physiology

Hepatomegaly Ascites peripheral edema pericardial rub distant heart sounds

Physical Exam
Pulsus Paradoxus

Seen in tamponade, not in restrictive cardiomyopathy, and only in severely constrictive pericarditis Effusive constrictive disease can produce tamponade like features. Inflate cuff and start to deflate slowly, the first Korotkoff sound will be heard only during expiration. Then the first Korotkoff sound will be heard during inspiration and expiration. The difference in pressures when this occurs is the measured pulsus paradoxus. Tamponade
Inspiration increases RV filling which pushes on LV thus decreasing LVEDV which decreases SV and SBP

Constrictive Pericarditis
Inspiration has no effect on ventricular filling because they are shielded by fibrotic pericardium Inspiration lowers pulmonary venous pressures, thereby decreasing gradient of flow into LV.

Studies
CXR

Cardiomegaly Pleural Effusions

Electrical Alternans

Studies
ECHO

Tamponade or Effusive-Constrictive
Remember that tamponade is clinical diagnosis Compression of RA Collapse of RV in diastole Increased respiratory variation of TV/MV flow

Constrictive
Pericardial thickening Dilated atria and vena cava

Studies
Cardiac Catheterization

Tamponade
Equalization of increased RA, PCW, RV and LV pressures throughout respiratory cycle Considerable respiratory variation

Constrictive
equalization of increased RA and PCW pressures, but CW pressures drop during inspiration, therefore not equal throughout respiratory cycle Intra-cardiac pressures have little respiratory variation

Effusive Constrictive
Similar to tamponade but constrictive features unmasked when fluid is removed

Differential Diagnosis
Malignancy Hemopericardium

Trauma Post-CABG Aortic dissection Iatrogenic s/p catheterization

Viral infections Radiation Connective tissue disorders Sarcoidosis Post-myocardial infarction Uremia

Diagnosis
There is no good diagnostic test!! PPD

Negative tests in non-HIV patient suggest it is not TB pericarditis Exudative, high protein fluid AFB present in only 40-60% patients Culture improves these figures somewhat Yield of diagnosis is only between 5 and 29%

Pericardiocentesis

Pericardial Biopsy

Adenosine Deaminase

In high endemic regions results are quite helpful with Sensitivity 91%, Specificity 68% in one South African study of 110 patients (they used a cut-off value of 30U/L)

Treatment
Medications

INH (300 mg orally once daily) Rifampin (600 mg orally once daily) Pyrazinamide (15 to 30 mg/kg per day up to 2 g/day given as a single dose) Ethambutol (15 to 20 mg/kg orally once daily)

8 weeks of four drug regimen followed by 18 weeks of INH and Rifampin daily Prednisone 60mg x 4 weeks, 30mg x 4 weeks, 15mg x 2 weeks, 5mg x 1 week

This was shown to decrease repeat pericardiocentesis, improve JVD by exam and decrease mortality

Pericardiectomy

Reserved for patients with recurrent effusions and continued elevation of CVP Better tolerated in patients that have not progressed to constrictive pericarditis

References
Sagrista-Sauleda, J, Permanyer-Miralda, G, Soler-Soler, J. Tuberculous pericarditis: Ten year experience with a prospective protocol for diagnosis and treatment. J Am Coll Cardiol 1988; 11:724. Strang, JIG, Kakaza, HSS, Gibson, DG, et al. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987; 2:1418. Up-to-date