Chronic adhesive pericarditis - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Shortness of breath Chronic (>3months) pericarditis leads to scarred, thickened, and frequently calcified pericardium which impairs cardiac filling, limiting the total cardiac volume.Patient may feel shortness of breath due to impaired cardiac out put Shortness of breath
Chronic (>3months) pericarditis leads to scarred, thickened, and frequently calcified pericardium which impairs cardiac filling, limiting the total cardiac volume.Patient may feel shortness of breath due to impaired cardiac out put
Fatigue Patient may feel fatigue due to impaired cardiac out put caused by scarred pericardium Fatigue
Patient may feel fatigue due to impaired cardiac out put caused by scarred pericardium
Palpitations Related to the degree of cardiac compression and pericardial inflammation Palpitations
Related to the degree of cardiac compression and pericardial inflammation
Chest pain Not so severe as in acute pericarditis. Pain occurs due to cardiac compression and pericardial inflammation Chest pain
Not so severe as in acute pericarditis. Pain occurs due to cardiac compression and pericardial inflammation
Poor exercise tolerance Due to impaired cardiac out put caused by cardiac compression Poor exercise tolerance
Due to impaired cardiac out put caused by cardiac compression
Depressions over the chest Due to sunken intercostal spaces caused by cardiac compression Depressions over the chest
Due to sunken intercostal spaces caused by cardiac compression
Past history of tuberculosis Tuberculosis can cause pericardial scar formation (tuberculous pericarditis) Past history of tuberculosis
Tuberculosis can cause pericardial scar formation (tuberculous pericarditis)
Past history of cardiac surgery Can cause scar formation in the paricardium Past history of cardiac surgery
Can cause scar formation in the paricardium
Past history of rheumatic heart disease Can cause scar formation in pericardium Past history of rheumatic heart disease
Can cause scar formation in pericardium
Systemic diseases eg: systemic lupus erythematosus Can give rise to scar formation in pericardium Systemic diseases eg: systemic lupus erythematosus
Can give rise to scar formation in pericardium
History of malignancy of chest or malignant infiltrate of chest / irradiation to chest Can cause scar formation in pericardium History of malignancy of chest or malignant infiltrate of chest / irradiation to chest
Can cause scar formation in pericardium

Clinicals - Examination

Fact Explanation
Dyspnoea Pericardial constriction occurs when a scarred, thickened, and frequently calcified pericardium impairs cardiac filling, limiting the total cardiac volume.Patient may be dyspneic due to impaired cardiac output Dyspnoea
Pericardial constriction occurs when a scarred, thickened, and frequently calcified pericardium impairs cardiac filling, limiting the total cardiac volume.Patient may be dyspneic due to impaired cardiac output
Rapid, feeble pulse /Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration ) Due to reduced cardiac out put caused by cardiac compression Rapid, feeble pulse /Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration )
Due to reduced cardiac out put caused by cardiac compression
Systolic tug Occur with each pulsation and may be seen near the sternum, between the seventh and eighth interspace Systolic tug
Occur with each pulsation and may be seen near the sternum, between the seventh and eighth interspace
Indrawn intercostal spaces posteriorly (Broadbent's sign) On examining the back of the patient a visible retraction of the chest will be observed between the eleventh and twelfth ribs, during each systole.Occurs due to adhesions Indrawn intercostal spaces posteriorly (Broadbent's sign)
On examining the back of the patient a visible retraction of the chest will be observed between the eleventh and twelfth ribs, during each systole.Occurs due to adhesions
Friedreich's sign Exaggerated drop in diastolic central venous pressure seen particularly with a stiff calcified pericardium and manifested as abrupt collapse of the neck veins or marked descent of the central venous pressure waveform Friedreich's sign
Exaggerated drop in diastolic central venous pressure seen particularly with a stiff calcified pericardium and manifested as abrupt collapse of the neck veins or marked descent of the central venous pressure waveform
Jugular venous distension Due to increased systemic venous pressure Jugular venous distension
Due to increased systemic venous pressure
Ascites, peripheral oedema Due to increased systemic venous pressure Ascites, peripheral oedema
Due to increased systemic venous pressure
Scar marks due to cardiac surgeries Can cause scar formation in pericardium due to cardiac surgeries Scar marks due to cardiac surgeries
Can cause scar formation in pericardium due to cardiac surgeries
Wasted apparance Due to tuberculosis which can give rise to tuberculous pericarditis giving rise to pericardial adhesion Wasted apparance
Due to tuberculosis which can give rise to tuberculous pericarditis giving rise to pericardial adhesion

Investigations - Diagnosis

Fact Explanation
Electrocardiogram (ECG) Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Electrocardiogram (ECG)
Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Chest x ray Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml
Also to identify other pathological conditions eg:tumours
Chest x ray
Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml
Also to identify other pathological conditions eg:tumours
Echocardiogram To assess the ejection fraction
Thickened pericardium (>2 mm) that can be imaged by echocardiography
Echocardiogram
To assess the ejection fraction
Thickened pericardium (>2 mm) that can be imaged by echocardiography
CT / MRI chest Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours CT / MRI chest
Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours

Investigations - Management

Fact Explanation
Electrocarigram Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Electrocarigram
Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Echocardiogram To assess the ejection fraction
Thickened pericardium (>2 mm) that can be imaged by echocardiography
Echocardiogram
To assess the ejection fraction
Thickened pericardium (>2 mm) that can be imaged by echocardiography
Chest x ray Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml
Also to identify other pathological conditions eg:tumours
Chest x ray
Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml
Also to identify other pathological conditions eg:tumours
Full blood count To assess general medical condition of the patient. eg: hemoglobin levels
Also there may be changes in the full blood count in certain diseases eg: changes in platelet counts in systemic lupus erythematosus
Full blood count
To assess general medical condition of the patient. eg: hemoglobin levels
Also there may be changes in the full blood count in certain diseases eg: changes in platelet counts in systemic lupus erythematosus
Elaectrocardiogram Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Elaectrocardiogram
Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity.
Early stage II: ST junctions return to the baseline, PR deviated.
Late stage II: T waves progressively flatten and invert
Stage III: generalised T wave inversions
Stage IV: ECG returns to pre pericarditis state
Chest x ray Tuberculous changes , other pathologies (tumours) can be identified Chest x ray
Tuberculous changes , other pathologies (tumours) can be identified
CT / MRI chest Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours CT / MRI chest
Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours

Management - Supportive

Fact Explanation
Non steroidal anti inflammatory drugs (NSAIDs) For pain relief. Non steroidal anti inflammatory drugs (NSAIDs)
For pain relief.
Colchicine If the pericardial pain and inflammation do not respond to NSAIDs Colchicine
If the pericardial pain and inflammation do not respond to NSAIDs

Management - Specific

Fact Explanation
Pericardiocentesis For diagnostic purposes. (tissue analysis) Pericardiocentesis
For diagnostic purposes. (tissue analysis)
Balloon pericardiotomy or pericardiectomy Should be considered for frequent and symptomatic recurrences Balloon pericardiotomy or pericardiectomy
Should be considered for frequent and symptomatic recurrences
Treat the specific cause eg:Treatment for tuberculous pericarditis Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied Treat the specific cause eg:Treatment for tuberculous pericarditis
Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. Corrigendum: Primary Purulent Pericarditis with Cardiac Tamponade due to Oropharyngeal Polymicrobial Infection: A Case Report and Literature Review. Korean J Thorac Cardiovasc Surg [online] 2014 Jun, 47(3):325 [viewed 30 September 2014] Available from: doi:10.5090/kjtcs.2014.47.3.325
  2. EKIM M, EKIM H. Diagnostic value of the biochemical tests in patients with purulent pericarditis Pak J Med Sci [online] 2014, 30(4):845-849 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121710
  3. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  4. KHANDAKER MH, ESPINOSA RE, NISHIMURA RA, SINAK LJ, HAYES SN, MELDUNI RM, OH JK. Pericardial Disease: Diagnosis and Management Mayo Clin Proc [online] 2010 Jun, 85(6):572-593 [viewed 06 July 2014] Available from: doi:10.4065/mcp.2010.0046
  5. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  6. PANDIE S, PETER JG, KERBELKER ZS, MELDAU R, THERON G, GOVENDER U, NTSEKHE M, DHEDA K, MAYOSI BM. Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous pericarditis compared to adenosine deaminase and unstimulated interferon-? in a high burden setting: a prospective study BMC Med [online] :101 [viewed 30 September 2014] Available from: doi:10.1186/1741-7015-12-101
  7. YAVUZ S, KASAP M, AKPINAR G, OZBUDAK E, URAL D, BERKI T. Analysis of pericardial effusion from idiopathic pericarditis patients by two-dimensional gel electrophoresis. Biomed Res Int [online] 2014:942718 [viewed 30 September 2014] Available from: doi:10.1155/2014/942718