cardiovascular-agents and Pericardial-Effusion

An overview of pericarditis, cardiomyopathy, and acute myocarditis is presented. Clinical presentation, causes, physical signs, laboratory testing, and various imaging procedures are discussed. Established pharmacologic and mechanical therapies are reviewed. Short-term and long-term prognoses, when relevant, are discussed.

Topics: Acute Disease; Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Anti-Inflammatory Agents, Non-Steroidal; Cardiac Resynchronization Therapy; Cardiomyopathies; Cardiovascular Agents; Defibrillators, Implantable; Echocardiography; Electrocardiography; Humans; Myocarditis; Pericardial Effusion; Pericarditis

The pericardium is composed of visceral and parietal components. In view of the pericardium's simple structure, pathologic processes involving it are understandably few. However, despite a limited number of clinical syndromes, the pericardium is affected by virtually every category of disease, including infectious, neoplastic, immune-inflammatory, metabolic, iatrogenic, and traumatic. Thus, the recognition of pericardial heart disease remains challenging. Treatment of pericardial disease is also problematic in that there is a paucity of randomized, placebo-controlled trials from which appropriate therapy may be selected and important clinical decisions assisted. This article reviews pericarditis and its sequelae, pericardial effusions, cardiac tamponade and constrictive pericarditis.

Topics: Cardiac Surgical Procedures; Cardiac Tamponade; Cardiovascular Agents; Evidence-Based Medicine; Humans; Pericardial Effusion; Pericardiectomy; Pericardiocentesis; Pericarditis; Pericarditis, Constrictive; Pericardium; Treatment Outcome

Topics: Animals; Cardiovascular Agents; Heart Diseases; Humans; Pericardial Effusion; Pericardium

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease which follows a relapsing and remitting course that can manifest in any organ system. While classic manifestations consist of arthralgia, myalgia, frank arthritis, a malar rash and renal failure to name a few, cardiac tamponade, however, is a far less common and far more dangerous presentation. We highlight the case of a 61year-old male with complaints of acute onset shortness of breath and generalized body aches associated with a fever and chills in the ER. A bedside echocardiogram revealed a significant pericardial effusion concerning for pericardial tamponade. An emergent pericardiocentesis performed drained 800mL of serosanguinous fluid. While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg. Subsequent lab work revealed ANA titer of 1:630 and anti-DS DNA antibody level of 256IU/mL consistent with SLE. This case highlights cardiac tamponade as a rare but life-threatening presentation for SLE and raises the need to keep it in the differential when assessing patients presenting with pertinent exam findings.

Topics: Antihypertensive Agents; Cardiac Tamponade; Cardiovascular Agents; Chills; Diltiazem; Dyspnea; Echocardiography; Fever; Humans; Lupus Erythematosus, Systemic; Male; Metoprolol; Middle Aged; Pericardial Effusion; Pericardiocentesis; Treatment Outcome

A 53-year-old woman with myelodysplastic syndrome received a cord blood transplant because she had frequent episodes of febrile neutropenia. As a conditioning regimen for transplant, she received 12 Gy total body irradiation, intravenous cytosine arabinoside 3 g/m2 every 12 hours on days -5 and -4, and cyclophosphamide 60 mg/kg/day on days -3 and -2. She received tacrolimus and short-term methotrexate treatment as prophylaxis for graft-versus-host disease. Her cardiac function was normal before transplant. She developed acute heart failure with a mild pericardial effusion 11 days after transplant, but her failure improved with a diuretic, vasodilator, and inotropic agent. She complained of dyspnea, and chest auscultation revealed pericardial friction rubs on day 28. Massive pericardial effusion was detected by echocardiography and pericarditis was diagnosed. The pericardial space was drained by pericardiocentesis. The pericardial fluid was exudative, but no bacteria or fungi were cultured. On viral polymerase chain reaction examination, human herpesvirus-6 was detected at a level of 3 × 104 copies/mL in the pericardial effusion, but not in the peripheral blood. With conservative treatment alone, that did not include antiviral therapy, her symptoms disappeared on day 56. We conclude that human herpesvirus-6 reactivation may have been associated with her pericarditis.

Topics: Cardiovascular Agents; Cord Blood Stem Cell Transplantation; DNA, Viral; Female; Heart Failure; Herpesvirus 6, Human; Humans; Immunosuppressive Agents; Middle Aged; Myelodysplastic Syndromes; Pericardial Effusion; Pericardiocentesis; Pericarditis; Roseolovirus Infections; Tomography, X-Ray Computed; Treatment Outcome; Virus Activation

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Cardiac Tamponade; Cardiovascular Agents; Chest Pain; Clinical Protocols; Critical Pathways; Disease Management; Echocardiography; Electrocardiography; Evidence-Based Practice; Heart Failure; Hemodynamics; Humans; Hypotension; Pericardial Effusion; Pericardiocentesis; Pericardium; Program Evaluation; Severity of Illness Index