STEPTRACKERCARDIOVASCULAR | PATHOLOGY + PHYSIOLOGY | HIGH-YIELD REVIEW

Pericardial Disease & Cardiac Tumors

Inflamed, fluid-filled or scarred pericardium — and the few tumors that arise in the heart itself.

FOCUS ON
Pericarditis: pain eased by leaning forward, friction rub, diffuse ST elevation with PR depression. Tamponade: Beck triad + pulsus paradoxus → pericardiocentesis. Constriction: Kussmaul sign + knock + calcified pericardium. Myxoma is the adult left-atrial tumor; rhabdomyoma is the childhood one (tuberous sclerosis).
CONDITION
CAUSES · MECHANISM
FINDINGS
CLUE · TREATMENT
Acute pericarditis
Idiopathic/viral (coxsackie B) most common; post-MI, Dressler, uremia, SLE/RA, TB, malignancy, radiation, post-surgery
Sharp pleuritic chest pain relieved by sitting forward; friction rub; diffuse concave ST elevation + PR depression
NSAIDs + colchicine · uremic → dialysis
Pericardial effusion
Serous (HF, low albumin), serosanguineous (TB, cancer), bloody (trauma, rupture)
Slow fluid is well tolerated; large effusions: low-voltage QRS, electrical alternans
Echo confirms
Cardiac tamponade
Rapid fluid → pericardial pressure equals diastolic pressures → chambers can't fill
Beck triad: hypotension, JVD, distant heart sounds; pulsus paradoxus (> 10 mmHg inspiratory drop); tachycardia
Trauma, dissection, free-wall rupture, cancer · emergency pericardiocentesis
Constrictive pericarditis
Fibrotic, calcified pericardium: TB (worldwide), radiation, cardiac surgery, viral (developed countries)
Kussmaul sign (JVP rises on inspiration), pericardial knock, ascites, edema, hepatomegaly
Calcified rim on CXR · pericardiectomy
Atrial myxoma
most common primary, adults
Benign gelatinous tumor of stellate cells in myxoid stroma; usually left atrium at the fossa ovalis
"Ball-valve" obstruction → positional syncope, dyspnea; early diastolic "tumor plop"; emboli; fever, weight loss (IL-6)
Carney complex (PRKAR1A): myxomas + spotty pigmentation + endocrine tumors
Rhabdomyoma
most common primary, children
Hamartoma of cardiac muscle; ventricles
Often found prenatally or in infancy; "spider cells"
Tuberous sclerosis; often regresses
Metastatic tumors
most common overall
Lung, breast, melanoma, lymphoma spread to pericardium/heart
Malignant (bloody) pericardial effusion, tamponade
Melanoma has a strong tropism for the heart
Primary cardiac sarcoma
Angiosarcoma most common malignant primary
Usually right atrium
Rare, poor prognosis

Mechanism — pressure in a closed sac

Fluid accumulates fast
→
Pericardial pressure ↑
→
Diastolic filling ↓All chambers equalize
→
Inspiration: RV fills, septum bows leftLV output ↓ → pulsus paradoxus
→
↓ Cardiac outputShock

Pulsus paradoxus also occurs in severe asthma, COPD and croup. Kussmaul sign appears in constrictive pericarditis, restrictive cardiomyopathy and RV infarction.

Tamponade vs constriction

FEATURE
TAMPONADE
CONSTRICTION
Onset
Acute
Chronic
Key sign
Pulsus paradoxus, Beck triad
Kussmaul sign, pericardial knock
ECG
Low voltage, electrical alternans
Low voltage
Imaging
Effusion, diastolic RA/RV collapse
Thick or calcified pericardium
Treatment
Pericardiocentesis
Pericardiectomy

How it's tested

COMMON CONFUSIONPericarditis ST elevation is diffuse and concave with PR depression. STEMI ST elevation follows one coronary territory, with reciprocal depression.
THE TRAPA patient after a stab wound has hypotension, JVD and muffled heart sounds. The next step is pericardiocentesis, not more fluids or a CT scan.
YOUR APPROACHChest pain + rub → pericarditis (find the cause). Shock + JVD → tamponade. Chronic right-sided congestion + clear lungs → constriction vs restriction.

If you see… think…

Pleuritic pain eased leaning forward + rub + diffuse ST↑ + PR↓ → acute pericarditis
BUN 140 with a friction rub → uremic pericarditis — dialysis
Stab wound, hypotension, JVD, muffled heart sounds → tamponade — pericardiocentesis
Systolic BP drops 15 mmHg on inspiration → pulsus paradoxus
QRS height alternating beat to beat → electrical alternans
JVP rises on inspiration + knock + calcified pericardium → constrictive pericarditis
Constriction in an immigrant from a TB-endemic country → tuberculous pericarditis
Positional syncope + diastolic plop + left atrial mass → atrial myxoma
Infant with tuberous sclerosis and a ventricular mass → rhabdomyoma
Most common tumor found in the heart → metastasis