Snapshot A 63-year-old male presents with severe chest pain that is alleviated by leaning forward. Physical exam reveals CVP and a friction rub best heard when the patient leans forward. ECG shows ST elevation in all leads and PR depression in the precordial leads. Introduction Inflammation of the pericardial sac resulting from acute or chronic pericardial insults often leads to pericardial effusion can compromise cardiac output via tamponade constrictive pericarditis Etiology most commonly idiopathic other known causes include SLE uremia viral infection TB RA neoplasms drugs radiation scleroderma may also occur following MI open heart surgery radiotherapy Anatomy The normal pericardium consists of two layers a fibrous outer layer the outer fibrous pericardium produces one of the most echo-producing areas of the heart. serous inner layer the serous layer is a closed sac with the visceral component lining the epicardium and the parietal component lining the fibrous outer layer. Presentation Symptoms dyspnea cough fever often following URI pleuritic chest pain worse when the patient is supine and during inspiration alleviated when the patient leans forward Physical exam pericardial friction rub best heard with patient leaning forward elevated JVP pulsus paradoxus raises concern for tamponade Evaluation Diagnosis is clinical Echocardiography is confirmatory may demonstrate pericardial thickening or effusion EKG low voltage overall PR depression in the precordial leads diffuse ST segment elevation T-wave inversions classic EKG changes are mostly absent in uremic pericarditis CXR primarily to rule out pneumonia may show signs of pericardial effusion constrictive pericarditis may show signs of pericardial calcifications Differential Cardiac tamponade, hemopericardium, heart failure, MI, pneumonia, pneumothorax Treatment Nonoperative observation & treatment of underlying cause indications in cases of asymptomatic or small pericardial effusion medical treatment of underlying condition NSAIDS for viral pericarditis steroids and immunosuppressants for SLE avoid immediately following MI to protect from ventricular wall rupture dialysis for uremia aspirin for post-MI pericarditis pericardiocentesis indications required for large effusions & cardiac tamponade Operative pericardiectomy reserved for recurrent disease Prognosis, Prevention, and Complications Prognosis depends highly on etiology of disease most cases resolve spontaneously Prevention onset is unpredictable in most cases early intervention for symptomatic relief large effusions might require continuous drainage to prevent more severe sequelae Complications effusion can lead to constrictive pericarditis or tamponade potentially resulting in death