Dialysis associated pericarditis
Uremic pericarditis may occur in 6-10% of patients with advanced renal failure after initiation of dialysis.
However, tuberculosis should be considered in endemic areas.
The widespread availability of dialysis has reduced the incidence of uremic pericarditis.
Acute pericarditis is more common in female than male
Malignant disease is the most common cause of pericardial effusion with tamponade in developing
Epidemiologic data on the incidence of acute pericarditis are lacking, likely because this condition is frequently unapparent clinically, despite its presence in numerous disorders
When patients with large effusions are studied, uremia may account for up to 20% of cases in some series.
Palpitations may be the presenting complaint, but chest pain is the cardinal symptom of pericarditis, usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm.
The quality of the pain is usually pleuritic, but it range from sharp, dull, aching, burning, or pressing, and the intensity varies from barely perceptible to severe.
The pain is worse during inspiration, when lying flat, or during swallowing and with body motion, and it may be relieved by leaning forward while seated.
A pericardial friction rub is pathognomonic for acute pericarditis; the rub has a scratching, grating sound similar to leather rubbing against leather.
More than 50% of pericardial friction rubs are triphasic: o An atrial systolic rub that precedes S1, o a ventricular systolic rub occurs between S1 and S2 and is coincident with the peak carotid pulse, and
o An early diastolic rub occurs after S2 (usually the faintest).
Chest radiography is not helpful in uncomplicated pericarditis.
Patients with small effusions (less than a few hundred milliliters) may present with a normal cardiac silhouette.
A flask-shaped, enlarged cardiac silhouette may be the first indication of a large pericardial effusion (200-250 mL of fluid accumulation) or cardiac tamponade
This occurs in patients with slow fluid accumulation, compared with a normal cardiac silhouette seen in patients with rapid accumulation and tamponade.
Thus, the chronicity of the effusion may be suggested by the presence of a huge cardiac silhouette.
The normal pericardium is a fibroelastic sac surrounding the heart that contains a thin layer of fluid.
Diseases of the pericardium may be isolated to the pericardium or associated with a number of systemic disorders.
The principal manifestations of pericardial disease are
acute pericarditis and
pericardial effusion, Two distinctly different clinical entities, which on occasion may be present simultaneously. In some cases, the clinical presentation of acute pericardial inflammation predominates, and the presence of excess pericardial fluid is clinically unimportant. In other cases, the effusion and its clinical consequences (ie, cardiac tamponade) are of primary importance.
Mnemonic: EnD INVATIon
Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial electrocardiographic (ECG) changes. Pericarditis and cardiac tamponade involve the potential space surrounding the heart or pericardium; pericarditis is one cause of fluid accumulation in this potential space, and cardiac tamponade is the hemodynamic result of fluid accumulation.
The pericardium normally contains as much as 20-50 mL of an ultrafiltrate of plasma. Approximately 90-120 mL of additional pericardial fluid can accumulate in the pericardium without an increase in pressure. The capacity of the atria and ventricles to fill is mechanically compromised with further fluid accumulation, which can result in marked increases in pericardial pressure, eliciting
reduced stroke volume,
decreased cardiac output, and
Hypotension (cardiac tamponade physiology).
In most cases of acute pericarditis, the pericardium is acutely inflamed and has an infiltration of polymorphonuclear (PMN) leukocytes and pericardial vascularization. Often, the pericardium manifests a fibrinous reaction with exudates and adhesions. The pericardium may develop a serous or hemorrhagic effusion.
A granulomatous pericarditis occurs with tuberculosis, fungal infections, rheumatoid arthritis (RA), and sarcoidosis.
Uremic pericarditis is thought to result from inflammation of the visceral and parietal layers of the pericardium by metabolic toxins that accumulate in the body owing to kidney failure The precise pathogenetic changes induced by these toxins when causing uremic pericarditis have not been elucidated, although a rough correlation with the degree and the duration of azotemia exists Uremic pericarditis may be associated with hemorrhagic or serous effusion, although considerable overlap exists. Hemorrhagic effusions are more common and result in part from uremia-induced platelet dysfunction. Some authors distinguish between 2 types of pericarditis in patients with renal failure. One type is uremic pericarditis, which occurs in patients with uremia who have never received dialysis. The other type is dialysis-associated pericarditis, which occurs in patients who are already receiving dialysis.
Serous pericarditis is usually caused by noninfectious inflammation such as occurs in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).
Fibrous adhesions rarely occur.
Fibrous and serofibrinous pericarditis represent the same basic process and are the most frequent type of pericarditis.
Common causes include acute myocardial infarction (MI), postinfarction (including Dressler syndrome), uremia, radiation, RA, SLE, and trauma.
Severe infections may also cause a fibrinous reaction, as does routine cardiac surgery.
Purulent or suppurative pericarditis due to causative organisms may arise from direct extension, hematogenous seeding, or lymphatic extension, or by direct introduction during cardiotomy.
Immunosuppression facilitates this condition.
Clinical features include fever, chills, and spiking temperatures.
Constrictive pericarditis is a serious potential complication.
Hemorrhagic pericarditis involves blood mixed with a fibrinous or suppurative effusion, and it is most commonly caused by tuberculosis or direct neoplastic invasion.
This condition can also occur in severe bacterial infections or in patients with a bleeding diathesis.
Hemorrhagic pericarditis is common after cardiac surgery and may cause tamponade. The clinical significance is similar to suppurative pericarditis.
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