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Treatment of viral pericarditis is generally symptomatic Aspirin (650 mg every 3 4 hours) or other nonsteroidal agents (eg, indomethacin, 100 150 mg daily in divided doses) are usually effective Corticosteroids may be beneficial in unresponsive cases In general, symptoms subside in several days to weeks The major early complication is tamponade, which occurs in less than 5% of patients There may be recurrences in the first few weeks or months Rare patients will continue to experience recurrences chronically These patients may require long-term antiinflammatory medications, either corticosteroids or colchicine Rarely, acute pericarditis may lead to constrictive pericarditis, when pericardial resection may be necessary (see below) Standard antituberculous drug therapy is usually successful for tuberculous pericarditis (see 9), but constrictive pericarditis can occur Uremic pericarditis usually resolves with the institution of or with more aggressive dialysis Tamponade is fairly common, and partial pericardiectomy (pericardial window) may be necessary Whereas anti-inflammatory agents may relieve the pain and fever associated with uremic pericarditis, indomethacin and systemic corticosteroids do not affect its natural history The prognosis with neoplastic effusion is dismal, with only a small minority surviving 1 year If it is compromising the clinical comfort of the

Pericardial effusion can develop during any of the processes previously discussed The speed of accumulation determines the physiologic importance of the effusion Because the pericardium stretches, large effusions (> 1000 mL) that develop slowly may produce no hemodynamic effects Smaller effusions that appear rapidly can cause tamponade Tamponade is characterized by elevated intrapericardial pressure (> 15 mm Hg), which restricts venous return and ventricular filling As a result, the stroke volume and pulse pressure fall, and the heart rate and venous pressure rise Shock and death may result

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Pericardial effusions may be associated with pain if they occur as part of an acute inflammatory process or may be painless, as is often the case with neoplastic or uremic effusion Dyspnea and cough are common, especially with tamponade Other symptoms may result from the primary disease A pericardial friction rub may be present even with large effusions In cardiac tamponade, tachycardia, tachypnea, a narrow pulse pressure, and a relatively preserved

Rienmuller R et al CT and MR imaging of pericardial disease Radiol Clin North Am 2004 May;42(3):587 601 [PMID: 15193931] Shabetai R Pericardial effusion: haemodynamic spectrum Heart 2004 Mar;90(3):255 6 [PMID: 14966038] Wang ZJ et al CT and MR imaging of pericardial disease Radiographics 2003 Oct;23 Spec No:S167 80 [PMID: 14557510]

systolic pressure are characteristic Pulsus paradoxus a greater than 10 mm Hg decline in systolic pressure during inspiration due to further impairment of LV filling is the classic finding, but it may also occur with obstructive lung disease Central venous pressure is elevated and there is no evident y descent in the RA, RV, or LV hemodynamic tracings Edema or ascites are rarely present; these signs favor a more chronic process

Laboratory tests tend to reflect the underlying processes (see causes of pericarditis above)

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Evidence of right heart failure with an elevated JVP, edema, hepatomegaly, and ascites No fall or an elevation of the JVP with inspiration (Kussmaul s sign) Echocardiographic evidence for septal bounce and reduced mitral inflow velocities with inspiration Catheterization evidence for RV-LV interaction, a square root sign, equalization of diastolic pressures, and normal pulmonary pressure

Chest radiograph can suggest chronic effusion by an enlarged cardiac silhouette with a globular configuration but may appear normal in acute situations The ECG often reveals nonspecific T wave changes and low QRS voltage Electrical alternans is present uncommonly but is pathognomonic It is due to the heart swinging within the large effusion Echocardiography is the primary method for demonstrating pericardial effusion and is quite sensitive If tamponade is present, the high intrapericardial pressure may collapse lower pressure cardiac structures, such as the RA and RV In tamponade, the normal inspiratory reduction in LV filling is accentuated due to RV/LV interaction and there is a > 25% reduction in maximal mitral inflow velocities Cardiac CT and MRI also demonstrate pericardial fluid and any associated contiguous lesions Diagnostic pericardiocentesis or biopsy is often indicated for microbiologic and cytologic studies; a pericardial biopsy may be performed relatively simply through a small subxiphoid incision Unfortunately, the quality of the pericardial fluid rarely leads to a diagnosis, and any type of fluid (serous, serosanguinous, bloody, etc) can be seen in most diseases

Inflammation can lead to a thickened, fibrotic, adherent pericardium that restricts diastolic filling and produces chronically elevated venous pressures In the past, tuberculosis was the most common cause of constrictive pericarditis, but the process now more often occurs after radiation therapy, cardiac surgery, or viral pericarditis; histoplasmosis is another uncommon cause

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