Pericardial disease remains an important cause of morbidity and mortality, spanning a complex spectrum from asymptomatic and transient to severely symptomatic and life threatening. Knowledge about the presenting symptoms, clinical findings, diagnosis and management is essential for effective clinical management.

This article focuses on the pertinent features of the major pericardial diseases seen in clinical practice and the recommended diagnostic and treatment strategies. In many cases the management of pericardial disease is based on best clinical practice; however, evidence based recommendations are emerging. Published data, gleaned from observing numbers of patients, must be crystallised into an individualised management plan.

THE NORMAL PERICARDIUM

The pericardium consists of two layers that surround the heart and the proximal aorta, pulmonary artery, vena cava and pulmonary veins. The thick fibrous outer layer, which attaches to the adventia of the major vessels, diaphragm, sternum and vertebrae, provides strong structural support for the heart.¹ The inner layer is a thin serous membrane composed of only a single row of mesothelial cells which lies both on the surface of the heart, where it is called the visceral pericardium, and by folding back on itself and underlying the fibrous layer, forms the lining of the parietal pericardium. Normally the pericardium is <2 mm thick. The pericardial space is a blind sac contained within the visceral and parietal pericardium and usually contains only a small amount of pericardial fluid. The transverse sinus is the part of the pericardial sac which lies between the great vessels and the oblique sinus lies posteriorly between the pulmonary veins.

Pericardial fluid is produced by the visceral pericardial cells and resembles an ultrafiltrate of plasma that serves to lubricate and reduce friction between the visceral and parietal pericardial surfaces. The pericardial fluid is drained by the thoracic and right lymphatic ducts. Normally there is between 10–50 …