Page 749 - Cardiac Nursing

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C HAPTER 30 / Pericardial, Myocardial, and Endocardial Disease 725
pericarditis. The need for early diagnosis has led to emphasis on Pericardiectomy, surgical removal of the pericardium, is the
24
biochemical tests such as the pericardial adenosine deaminase test, treatment for symptomatic constrictive pericarditis. The proce-
and the use of interferon as an indicator of pericardial disease due dure may be either a total or a partial pericardiectomy. In a recent
to tuberculosis. 16 study, total pericardiectomy was associated with lower periopera-
Echocardiography is critical to assess the pericardium in peri- tive and late mortality, as well as a better hemodynamic condition
cardial disease. Computed tomography (CT) and magnetic reso- for the patient. 22 Idiopathic etiology was associated with better
nance imaging (MRI) allow examination of the entire chest, so ab- outcomes in two studies. 22,24
normalities that might be related to the pericardial findings can be Recurrent Pericarditis. Recurrent pericarditis is a complica-
assessed.
tion of acute pericarditis. Recurrence is diagnosed by recurrent
pain and one or more of the following signs: fever, pericardial fric-
Medical Management tion rub, ECG changes, effusion on echocardiography, and eleva-
The goal of treatment in acute pericarditis is to relieve pain and tion of white blood count, C-reactive protein level, or the ery-
9
prevent complications. Treatment of the underlying cause is also throcyte sedimentation rate. 17 The rate of recurrence is reported
a priority. Nonsteroidal anti-inflammatory drugs (NSAIDs) are to vary from 15% to 50%. It is considered an autoimmune phe-
the mainstay of treatment. Ibuprofen is preferred by many clini- nomenon. 17 Imazio et al. 17,29 found an increased risk of recur-
cians due to its rare side effects, favorable impact on coronary rence if corticosteroids were used during treatment of the first
2
flow, and large dose range. Depending on the severity and re- episode of pericarditis. Risk factors for recurrence in another
sponse, 300 to 800 mg every 6 to 8 hours may be initially re- study were identified as female gender, previous use of corticos-
quired, and is best continued until the effusion is resolved, which teroids, and previous recurrent pericarditis. 30 Use of colchicine
11
may be days or weeks. Aspirin (325 to 650 mg four times a day) along with NSAIDs during a first episode of pericarditis has been
3
is also commonly used to treat pericarditis. Gastrointestinal pro- found to decrease recurrence. 29
tection during NSAID therapy is important. 3,11,17 Colchicine Approximately 20% of pericarditis patients have a recur-
(0.5 or 6 mg b.i.d.) added to an NSAID or as monotherapy also rence within months, or rarely, within years. 31 In a systematic
appears to be effective in initial episodes, and to prevent recur- review spanning 40 years of literature on patients with idio-
rences. 11,12 Systemic corticosteroid therapy is recommended only pathic recurrent pericarditis, the complication rate of pericar-
in connective tissue diseases, autoreactive or uremic pericardi- dial tamponade was 3.5%, and no patients developed constric-
tis. 3,11 Intrapericardial corticosteroids have been effective and do tive pericarditis. 32
not cause systemic side effects. 11 Pericarditis Associated With MI
Pericarditis due to bacterial infections such as tuberculosis is
treated by directing treatment to the cause. The mainstay of treat- Early Acute Post-MI Pericarditis. In the immediate period
ment of tuberculosis pericarditis in Africa is the 6-month course after MI, an early pericardial syndrome may develop and then re-
of antituberculosis drugs recommended by the World Health Or- solve over a period of approximately 1 week. Pericardial involve-
33
ganization. 18 Pericardiocentesis is recommended in all patients ment is correlated to infarct size. The ECG shows a typical pat-
suspected of tuberculosis to facilitate diagnosis. 19 tern of pericarditis and is helpful in differentiating between
pericardial and ischemic pain. Pericardial friction rubs may be
Constrictive Pericarditis. Constrictive pericarditis results heard. As in all pericarditis, rubs are virtually 100% specific, but
from a scarred, and often thickened and calcified pericardium that sensitivity depends on frequency of auscultation, because they tend
20
limits diastolic ventricular filling. Tuberculosis is responsible for to come and go over hours. 12 The course is usually benign, and
most cases of constrictive pericarditis in Africa and Asia. 21 Other treatment consists of aspirin or other NSAIDs. Treatment of MI
causes of constrictive pericarditis are idiopathic, postradiation, with thrombolysis and mechanical revascularization appear to have
and postsurgical. 22,23 reduced the incidence of this form of pericarditis by at least 50%. 33
The often thickened, adherent pericardium restricts ventricular
filling and limits chamber expansion and maximal diastolic vol- Dressler’s Syndrome. Dressler’s syndrome of chest pain,
umes. End-diastolic pressures in all heart chambers are typically el- pleurisy, pericarditis with friction rub, severe malaise, moderate
evated and equalized. During classic constriction, Kussmaul’s sign, fever, and leukocytosis occurs 3 weeks to several months post-MI.
inspiratory jugular venous distention, replaces the normal inspira- The underlying pathologic process is unknown, but it is thought
tory venous “collapse” that reflects a normal inspiratory decrease of to reflect a late autoimmune reaction mediated by antibodies to
3 to 7 mm Hg in right atrial pressure. This sign is a hallmark of circulating antigens. 34 In contrast to early post-MI pericarditis,
2
constrictive pericarditis. Patients present with signs of heart fail- inflammation is diffuse and not localized to the myocardial injury
ure, although pulmonary edema is usually not a feature. 3,24 site. 33
A calcified pericardium is often visible on chest x-ray film. 25,26
CT, MRI, and echocardiography are tools also used to diagnose Pericardial Effusion
3
constrictive pericarditis. CT allows detection of calcification that
5
occurs in restrictive pericarditis. Many abnormal findings can be Pericardial effusion is an increased amount of fluid within the
seen on the echocardiogram that indicate constrictive pericarditis, pericardial space. This fluid can be serous, serosanguineous, pus,
such as premature opening of the pulmonic valve and rapid pos- lymph, or blood. 3
terior motion of the left ventricular posterior wall in early diastole,
with little or no posterior motion during the rest of diastole. Etiology
However, these findings are not specific for constrictive pericardi- Many conditions cause acute pericarditis and pericardial effu-
tis and can be caused by other conditions, such as restrictive car- sions, including uremia, tuberculosis, neoplasms, and connec-
diomyopathy (RCM). 27,28 tive tissue diseases. The effusion may also be associated with