Pattern of Pericardial Disease in the Asir Region of Saudi Arabia

Introduction

Pericardial disease is a significant cause of morbidity and mortality in any hospital setting. Four important clinical syndromes have been recognized, which are acute pericarditis, pericardial effusion, cardiac tamponade and pericardial constriction. The pattern of pericardial disease has been well documented in the Western literature,^1–5 which shows pericardial disease as most frequently secondary to acute myocardial infarction (most cases of transmural infarction are associated with localized pericarditis, and in about 10% of patients it is symptomatic). The second most common variety is ideopathic or viral pericarditis. Small pericardial effusions are frequently present in any case of acute pericarditis. The most common causes of large effusions are tuberculosis, malignancy, cardiac trauma, uremia and myxedema. In the West, the most frequent cause of cardiac tamponade is malignancy. In contrast, the literature published from Saudi Arabia lacks information on local experience. We therefore retrospectively studied the clinical features, laboratory investigations, management and outcome of 46 patients with pericardial disease who were admitted to hospital over a four-year period from 1993 to 1996.

PATIENTS AND METHODS

All patients with diagnosis of pericardial disease, both primary and secondary, were included. The study was conducted in the Cardiology Unit of the Asir Central Hospital, which is a 600-bed teaching hospital in Abha, in the southern region of Saudi Arabia. Pericardial disease was diagnosed when at least two of the following criteria were present: characteristic chest pain; pericardial friction rub; serial repolarization changes on ECG; and pericardial effusion on echocardiogram.

Cardiac tamponade was diagnosed when clinical impression was confirmed by the following echo-Doppler criteria: echocardiographic evidence of diastolic collapse of right atrium and right ventricle;^10,11 Doppler ultrasound findings of exaggerated respiratory variation in transvalvar flow velocities; and cross tricuspid, pulmonic and mitral valve.^12,13

Demographic information, presenting symptoms and signs, results of laboratory investigations and outcome were recorded according to a structural flow sheet. Simple descriptive statistics as well as chi-squared test were used for the comparison of diagnostic value between pericardiocentesis and pericardial biopisy. AP<0.05 was considered significant.

RESULTS

There were 46 patients, representing 2.9% of the total cardiac admissions during the period of the study. The age range was 13 to 71 years, with a median of 32. The majority of patients (75%) were Saudi nationals and 67% were males.

Table 1 shows the common presenting symptoms and signs. Chest pain and shortness of breath were the most common symptoms. Additional symptoms noted were cough, fever, general ill health and fatigability. Pericardial friction rub, the pathognomonic physical finding of acute pericarditis, was detected in 23 (50%) patients.

Table 1. Commonly presenting symptoms and signs.

Table 2 shows the results of non-invasive laboratory tests. Unfortunately, viral serology was not available and collagen screen was done in only eight patients.

Table 2. Results of laboratory tests.

Pericardiocentesis and pericardial biopsy were performed in 15 (33%) patients. The patients who had pericardiocentesis also had left thoracotomy, with the performance of pericardial window and pericardial biopsy. In five of the 15 patients (33%) who underwent pericardiocentesis, a definite diagnosis was reached, compared to 10 out of the 15 (66%) who were diagnosed by pericardial biopsy. Pericardiocentesis identified four patients of tuberculous pericarditis and three patients of pyogenic pericarditis. Pericardial biopsy identified eight cases of tuberculosis, which included four patients identified by pericardiocentesis, and one patient with hydatid cyst. Three patients had both end-stage renal disease and tuberculosis.

Uremia (11 patients, 24%) and tuberculosis (8 patients, 17%) were the most common causes identified. Other causes were pyogenic pericarditis (three patients, 7%), myocardial infarction (three patients, 7%), neoplastic (Hodgkin's) lymphoma (one patient, 2%), hydatid cyst (one patient, 2%), rheumatoid arthritis (one patient, 2%) and trauma (one patient, 2%). In 17 patients (36%), no cause of the disease was identified. Tuberculous, uremic and pyogenic pericarditis were most frequently associated with pericardial effusion and tamponade. Table 3 shows the relative prevalence of tamponade and pericardial effusion in different etiologies.

Table 3. Prevalence of effusion and tamponade.

DISCUSSION

The present study describes the clinical aspects of pericardial disease in a teaching hospital in Saudi Arabia. Clinical features generally conformed to the well-established pattern in the literature,^4–5 however, shortness of breath was a more prominent symptom in our study, accounting for 67% of patients. As clinical and radiological evidence of left ventricular failure was found in only 4% of cases, this symptom was not simply related to left ventricular failure. In our series, there was a high prevalence of diseases which have lung involvement, such as tuberculosis and pneumonia. These diseases, therefore, can partially explain the higher incidence of shortness of breath. The electrocardiographic and radiological features in our patients did not differ from those reported in the literature.^17–19 The diagnostic yield of pericardial biopsy (66%) was higher than pericardiocentesis (33%) (P-value >0.05). This did not attain statistical significance because of the small size of the sample. However, the limitation of pericardiocentesis in the diagnosis of tuberculous pericarditis has been reported in previous studies.^1–6 In our series, pericardiocentesis alone produced four false-negative results when histopathology of pericardial biopsy showed evidence of tuberculous pericarditis. This emphasizes the importance of histopathological diagnosis in such conditions.

Uremic and tuberculous pericarditis were found to be the most common causes of pericardial disease in our study. The higher frequency of tuberculosis and uremic pericarditis probably reflects the spectrum of diseases prevailing in our area, where tuberculosis is still common²¹ and end-stage renal disease is frequent.²²

In 17 patients (36%), no definite etiology was found. This could be due to the failure to screen those patients for viral infections and connective tissue disorders. However, those 17 patients had self-limited courses which responded to bed rest and salicylates. None of these patients died. Thus, we believe that this group may have suffered from mild viral or ideopathic pericardial disease. Three patients had pyogenic pericarditis, most likely secondary to pneumonia. The association between pyogenic pericarditis and pneumonia has previously been reported in the literature.^7,8 This can be prevented by adequately treating pneumonia according to bacteriological evidence. Surprisingly, only one case of malignant pericarditis (Hodgkin's lymphoma) was found, in contrast to the Western literature, where malignancy is a common cause of pericardial disease.^1–5 This could be attributed to the low prevalence of malignant diseases in the Middle East as compared to the West, although underdiagnosis of such conditions may be another factor in accounting for this rarity.

We conclude that in the Asir region of Saudi Arabia, uremia and tuberculosis are the common causes of specific pericardial disease. These causes, therefore, should be particularly considered in the context of pericardial disease. Moreover, pericardial biopsy should be the diagnostic procedure of choice if a specific diagnosis such as tuberculosis is suspected. In our series, we found it to be a very safe procedure.