PERICARDITIS

• Pericarditis refers to an inflammation and irritation of the pericardium, the fibroserous sac that envelops, supports, and protects the heart.

Etiology

• Idiopathic or nonspecific causes

• Infection:
  • usually viral - coxsackie virus, influenza, HIV
  • rarely bacterial - streptococci, staphylococci, meningococci, gonococci, gram-negative rods
• Mycotic (fungal)
• Disorders of connective tissue - systemic lupus erythematosus, rheumatic fever, rheumatoid arthritis, polyarteritis, scleroderma
• Hypersensitivity states: immune reactions, medication reactions, serum sickness
• Etiology
• Disorders of adjacent structures: myocardial infarction, Post MI (Dressler's syndrome), dissecting aneurysm, pleural and pulmonary disease (pneumonia)
• Neoplastic disease: caused by metastasis from lung cancer or breast cancer, leukemia, and primary (mesothelioma) neoplasms
• Radiation therapy of chest and upper torso (peak occurrence 5–9 months after treatment)
• Trauma: chest injury, cardiac surgery, cardiac catheterization, implantation of pacemaker or implantable cardioverter defibrillator (ICD)
• Renal failure and uremia
• Tuberculosis

Classification

• Pericarditis can be classified according to the composition of the inflammatory exudate or the fluid that accumulates around the heart. Types include:
  • Serous (serum)
  • Purulent (pus)
  • Calcific (calcium deposits)
  • Fibrinous (clotting proteins)
  • Sanguinous (blood)
• Depending on the time of presentation and duration, pericarditis is divided into
  • Acute pericarditis - is more common (<6 span="" weeks="">
  • Chronic pericarditis - is less common, (>6 months)

Clinical Manifestation

• Chest pain –
  • Substernal or left precordial pleuritic chest pain
  • Radiation to the trapezius ridge (the bottom portion of scapula on the back),
  • Relieved by sitting up and bending forward
  • Worsened by lying down (recumbent or supine position) or inspiration (taking a breath in)
• Other symptoms may include dry cough, fever, fatigue, and anxiety.

Characteristic	Pericarditis	Myocardial infarction
Pain description	Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain	Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
Radiation	Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation.	Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion	Does not change the pain	Can increase the pain
Position	Pain is worse in the supine position or upon inspiration (breathing in)	Not positional
Onset/duration	Sudden pain, that lasts for hours or sometimes days	Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours

Physical examinations / signs

• The classic sign of pericarditis is a friction rub auscultated on the lower left sternal border.
• Other physical signs include –
  • distress,
  • positional chest pain,
  • diaphoresis (excessive sweating),
  • possibility of heart failure in form of precardial tamponade causing pulsus paradoxus,
  • Beck's triad of hypotension (due to decreased cardiac output),
  • distant (muffled) heart sounds,
  • JVD (jugular vein distention)

Diagnosis

• Laboratory tests - CBC, ESR, CRP, BUN – Elevated
• Cardiac markers - Troponin (I, T), CK-MB, Myoglobin, and LDH₁ – increased
• ECG - Diffuse ST - elevation and PR segment depression
• Chest X-Ray - may be normal, but if there is a significant pericardial effusion, the heart shape may be abnormal.
• Echocardiogram – Done if evidence of pericardial effusion
• Other - CT or MRI scans of the heart and surrounding structures are examined

Complication

Pericardial Effusion

• A pericardial effusion occurs when an abnormal amount of fluid builds up within the pericardial space.
• This is most often asymptomatic, however it can be accompanied by pericarditis and it can on occasion cause "cardiac tamponade", a potentially fatal condition.
• Acutely, the pericardial space can't tolerate large increases in fluid, however if the fluid accumulates over a long period of time, up to 2 liters (2000 mL) of fluid can accumulate with minimal symptoms.
• Complication

Constrictive Pericarditis

• Constrictive pericarditis occurs when the pericardium becomes severely scarred over a long period of time resulting in impaired relaxation of the myocardium.
• This leads to diastolic heart failure over time.
• Causes include anything that may result in pericarditis.
• Symptoms are predominantly from right sided heart failure.
• Treatment is surgical pericardial stripping to relieve the constriction. This is difficult due to the severe scarring.
• Complication

Cardiac Tamponade (Emergency)

• Cardiac tamponade is a condition in which a pericardial effusion exerts large amounts of pressure on the myocardium restricting the relaxation of the heart.
• This causes severe diastolic dysfunction and can result in severe heart failure very quickly.
• The pressure of the pericardial space is dependant on the rapidity of fluid accumulation and the volume of fluid present. If fluid collects quickly, pressure rises rapidly since there is no time for the heart to compensate.

Management

• Goal of management are to determine the cause, to administer therapy for the specific cause (when known), and to watch for cardiac tamponade.
• Bed rest is instituted when cardiac output is impaired until fever, chest pain, and friction rub have disappeared. Then a gradual increase in activity is permitted as the patient's condition improves.
• Pharmacologic Therapy
  • Narcotic analgesic agents for pain relief during the acute phase
  • Analgesic agents and nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain and hasten reabsorption of fluid in rheumatic pericarditis. Colchicine may also be used as an alternative medication.
  • Corticosteroids to control symptoms, hasten resolution of the inflammatory process, and prevent recurring pericardial effusion
  • Penicillin for pericarditis of rheumatic fever
  • Isoniazid, ethambutol, rifampin, and streptomycin for pericarditis of tuberculosis
  • Amphotericin B for fungal pericarditis
• Surgical Management - require in case of Cardiac Tamponade
  • Thoracotomy for penetrating cardiac injuries
  • Pericardiocentesis for pericardial fluid removal
  • Pericardiectomy - Surgical removal of the tough encasing pericardium

Nursing Management

Nursing Diagnoses

• Acute pain related to inflammation of the pericardium
• Collaborative Problems / Potential Complications - Pericardial effusion and Cardiac tamponade 

Nursing Interventions

Relieving Pain

• Advise bed rest or chair rest in a sitting-upright and leaning-forward position.
• Instruct patient to resume activities of daily living as chest pain and friction rub abate.
• Administer medications; monitor and record responses.
• Instruct patient to resume bed rest if chest pain and friction rub recur.

Monitoring and Managing Potential Complications

• Observe for pericardial effusion, which can lead to cardiac tamponade: arterial pressure falls; systolic pressure falls while diastolic pressure remains stable; pulse pressure narrows; heart sounds progress from being distant to imperceptible.
• Observe for neck vein distention and other signs of rising central venous pressure.
• Notify physician immediately upon observing any of the above symptoms, and prepare for pericardiocentesis. Reassure patient and continue to assess and record signs and symptoms until physician arrives.