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KEY POINTS
The diagnosis of acute pericarditis can be made on the basis of two or more of the following: typical chest pain, a characteristic pericardial friction rub, distinctive electrocardiographic abnormalities, and new or worsening pericardial effusion.
Echocardiography is the initial imaging test of choice to detect pericardial effusion, and once detected, classifies effusions according to their size, distribution, onset, hemodynamic impact, and composition.
High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine are effective medical therapy for acute pericarditis, except in cases due to acute coronary syndromes, where NSAIDs are contraindicated and replaced with aspirin.
The key echocardiographic signs of cardiac tamponade include the presence of a pericardial effusion, small cardiac chambers, and a plethoric (dilated) inferior vena cava; supportive signs include those related to increased pericardial pressure (right-sided chamber collapses) and signs related to increased ventricular interdependence (excessive respiratory variation of transvalvular velocities).
The echocardiographic diagnosis of cardiac tamponade may be difficult in cases of regional tamponade that can occur postoperatively, in the presence of atrial fibrillation, and when pericardial effusions coexist with large pleural effusions.
Cardiac tamponade is a hemodynamic condition characterized by equal elevation of atrial and pericardial pressures, an exaggerated (>10 mm Hg) decrease in arterial systolic pressure (pulsus paradoxus) as a function of breathing, and arterial hypotension. In patients in whom invasive monitoring is available, cardiac tamponade manifests as blunting or absence of the y descent, elevation in filling pressures, tachycardia, and reduced cardiac output.
The diagnosis of constrictive pericarditis can be made with echocardiography in most patients, with invasive catheterization reserved for patients in whom the clinical findings and noninvasive studies cannot definitively establish the diagnosis.
The key echocardiographic signs of constrictive pericarditis are due to increased pericardial restraint (restrictive LV filling pattern), increased ventricular interdependence (abnormal septal motion), dissociation of intrathoracic and intracardiac pressures (excessive respiratory variations of transvalvular flows), elevated diastolic pressures (vena caval plethora, biatrial enlargement), and tethering of the mitral valve ring to the pericardium (annulus reversus).
Effusive-constrictive pericarditis should be suspected in patients with a pericardial effusion and pericardial thickening; in those with echocardiographic signs of tamponade before and signs consistent with constrictive pericarditis after pericardiocentesis; and if pericardiocentesis fails to decrease the right atrial pressure by 50% or to a level below 10 mm Hg.
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The diagnosis of pericardial disease in the intensive care unit (ICU) is often challenging; it is encountered less frequently than myocardial disease and is commonly overlooked. The intensivist is likely to see the patients with pericardial disease in a variety of settings, either as an isolated phenomenon or as a symptom or complication of a systemic disorder (eg, aortic dissection), trauma, or certain drugs. In these latter settings, pericardial involvement may be overshadowed by extracardiac manifestations. On the contrary, pericardial disease may imitate ischemic heart disease and heart failure and be a source of clinical uncertainty. While many patients with pericardial disease have a subacute ...