Pericardial & Aortic Disease
The inflamed sac, the squeezed heart, and the tearing aorta
Acute pericarditis
Presentation. Sharp, pleuritic chest pain that improves when the patient sits up and leans forward and worsens lying supine, often with a scratchy pericardial friction rub. The diagnosis generally needs two of four features: typical pain, a rub, characteristic ECG changes, or a new or enlarging effusion. ESR and CRP are elevated; a mildly raised troponin suggests accompanying myocarditis.
Causes. Viral or idiopathic (coxsackievirus) most often; also post-MI, uremia, tuberculosis, autoimmune disease, and malignancy. Post-MI pericarditis is either early peri-infarct pericarditis (days) or Dressler syndrome (an autoimmune form weeks later).
| Feature | Pericarditis | STEMI |
|---|---|---|
| ST elevation | Diffuse, across most leads | Regional, one artery's territory |
| PR segment | PR depression (PR elevation in aVR) | No PR depression |
| Reciprocal ST depression | Absent (except aVR) | Present |
| Pain and exam | Positional, pleuritic; friction rub | Crushing, not positional; high troponin |
Treatment. An NSAID plus colchicine for viral or idiopathic pericarditis; colchicine reduces recurrence. After an MI, use aspirin instead of other NSAIDs, which impair myocardial healing. Reserve corticosteroids for refractory or autoimmune cases, because steroids increase recurrence. Uremic pericarditis often lacks the typical diffuse ST elevation and is an indication for dialysis.
Effusion and cardiac tamponade
Rate beats size. Fluid in the pericardial sac compresses the heart and impairs diastolic filling. How fast it accumulates matters most: a small effusion that forms quickly (trauma, free wall rupture, type A dissection) can tamponade, while a large one that builds slowly (malignancy, uremia) may not.
Findings.
- Beck triad: hypotension, jugular venous distension, and muffled heart sounds, usually with tachycardia.
- Pulsus paradoxus: an inspiratory fall in systolic BP of more than 10 mmHg. Inspiration fills the right ventricle, the septum bows into the fixed-volume left ventricle, and LV output drops.
- ECG: low voltage and electrical alternans, a beat-to-beat swing in QRS amplitude as the heart swings in fluid.
- Chest radiograph: an enlarged, "water-bottle" cardiac silhouette with a large effusion.
Echo confirms the diagnosis: diastolic collapse of the right atrium and ventricle and a plethoric IVC.
Drain it, don't diurese it. Treatment is urgent pericardiocentesis, with IV fluids to temporize. Diuretics and vasodilators (nitrates) are dangerous because the heart depends on preload.
Constrictive pericarditis
The rigid shell. A scarred, often calcified pericardium limits filling throughout diastole. Causes include tuberculosis (the leading cause worldwide), prior cardiac surgery, and radiation. Patients present with right-sided failure out of proportion to lung findings: fatigue, edema, hepatomegaly, and ascites that can mimic liver disease.
Signs. Elevated JVP with prominent x and y descents, Kussmaul sign (JVP rises with inspiration), an early diastolic pericardial knock, pericardial calcification on imaging, and a square-root (dip-and-plateau) ventricular pressure tracing. Definitive treatment is pericardiectomy.
| Feature | Tamponade | Constrictive pericarditis |
|---|---|---|
| Problem | Fluid under pressure | Rigid, thickened pericardium |
| Pulsus paradoxus | Characteristic | Not the classic feature |
| Kussmaul sign | Absent | Present |
| Extra sound | Muffled heart sounds | Pericardial knock |
| Treatment | Urgent pericardiocentesis | Pericardiectomy |
Aortic dissection
Presentation. Sudden, tearing chest pain radiating to the back, with an inter-arm BP difference of more than 20 mmHg and often a widened mediastinum on chest radiograph. Hypertension is the most common risk factor; others are Marfan and Ehlers-Danlos syndromes, bicuspid aortic valve, cocaine, and pregnancy. Extension can cause acute aortic regurgitation, tamponade, MI (often inferior, from the right coronary ostium), stroke, and limb or kidney ischemia.
Imaging. CT angiography if the patient is stable; TEE if unstable. Anticoagulants and thrombolytics are contraindicated, which is why dissection must be excluded before treating presumed MI or stroke when features overlap.
| Feature | Type A | Type B |
|---|---|---|
| Location | Ascending aorta, with or without the arch | Descending aorta only, distal to the left subclavian |
| Dangers | Tamponade, aortic regurgitation, coronary or carotid occlusion | Malperfusion or rupture if complicated |
| Management | Emergent surgery | Medical (heart rate and BP control) unless complicated; then endovascular repair |
- IV β-blocker firstEsmolol or labetalol to a heart rate below 60, reducing aortic shear stress (dP/dt).
- Then a vasodilator if neededNitroprusside to a systolic BP of 100–120; giving it first causes reflex tachycardia that extends the tear.
- Pain controlIV opioids blunt sympathetic surges.
- Definitive careType A to surgery; type B medical unless complicated.
Abdominal aortic aneurysm
Screening. A one-time abdominal ultrasound for men aged 65–75 who have ever smoked; smoking is the strongest modifiable risk factor. Screening is offered selectively to men who never smoked and is not routine for women.
Repair thresholds. Elective repair (open or endovascular) at a diameter of ≥5.5 cm, rapid growth (more than 0.5 cm per year), or symptoms such as tenderness or back pain. Smaller aneurysms are followed with serial ultrasound, more often as they enlarge, alongside smoking cessation and risk-factor control. Thoracic aneurysms from Marfan syndrome or a bicuspid valve are repaired at lower diameters.
Rupture presents with hypotension, a pulsatile abdominal mass, and back or flank pain. An unstable patient goes straight to the operating room without imaging.