Pericarditis. (With particular reference to tuberculous pericarditis).

Abstract

SummaryIn this study diseases of the pericardium which dominate the clinical picture have been analysed. In essence this means a discussion of infective pericarditis.Pericarditis is a common disorder in Cape Town, South Africa, particularly among the Bantu and Cape Coloured population. The high incidence in the non‐White races is attributed to tuberculosis, mainly as a result of socio‐economic conditions. Tuberculosis was found to be the cause in 40% of the patients; the diagnosis was established by the finding of pericardial fluid, which gave positive results on testing for tuberculosis, positive histological evidence or adequate evidence of associated organ tuberculosis. In another 40% of patients, tuberculosis appeared to be the most likely cause of the condition, on clinical grounds which are described. Twelve per centum of cases were due to causes unknown, a tuberculous or viral cause being the most likely. In 6% of cases the pericarditis was pyogenic. A few other uncommon conditions were also present.The clinical syndromes of dry pericarditis, pericarditis with effusion and constrictive pericarditis are described. The most important symptom is a distinctive type of chest pain due to inflammation of the pericardium. The important findings are a pericardial friction rub, systemic venous hypertension and pulsus paradoxus. Sudden splitting of the second sound in inspiration is more characteristic than the early third heart sound, and occurs far more frequently. The electrocardiogram is usually abnormal, drawing attention to the heart, but not very helpful in establishing the diagnosis. The findings on X‐ray examination confirm the cardiomegaly in cases of effusion and in most cases of constrictive pericarditis. A cardiac shadow of normal size was uncommonly seen, and pericardial calcification occurred in a minor proportion of the cases in this series. Cardiac catheterization and angiocardiography was seldom required to establish the diagnosis.The pericardium should be aspirated whenever an effusion is suspected, and aspiration is a safe procedure with an electrode needle under electrocardiographic control.The course of pericardial effusion and constrictive pericarditis (in 195 and 220 patients respectively) is discussed, with particular reference to tuberculosis.With tuberculous pericardial effusions from which acid‐fast bacilli were recovered there was an extremely high incidence of progression of the condition to constrictive pericarditis requiring surgery. Even when the fluid was sterile, most patients developed constriction and surgery was usually required, but the rate of ultimate cure was over 90%.Of 195 patients presenting with pericardial effusion, irrespective of the cause over half developed the signs of constrictive pericarditis, and 40% required surgery. A small but significant percentage of patients, however, can pass through the phase of constriction and ultimately recover without operation.There were 220 patients with constrictive pericarditis. In 38 the process was chronic, the only effective treatment being surgical. Seventy‐eight presented with active pericarditis producing constriction without effusion. Most of these required surgical treatment, but a quarter recovered on conservative therapy alone. The remaining 104 developed pericardial constriction after their disease had passed through a phase of effusion, surgery being necessary for 75%. The overall surgical results were better than the results of medical therapy, which consisted of the use of antituberculous drugs, digitalis and diuretics.Surgery has a great deal to offer in the treatment of pericarditis, but the time to recommend this procedure must be carefully chosen.