Pericardial Friction Rub

Article Author:
Johnny Chahine

Article Editor:
Waqas Siddiqui

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Phillip Hynes

5/13/2019 9:03:42 AM


A pericardial rub is highly specific for acute pericarditis. It is generally heard over the left sternal border, louder at inspiration and on bending forward. In most cases, the rub is triphasic (audible in atrial, ventricular systole and ventricular diastole phases) and is of high frequency.[1]

Issues of Concern

The prevalence of a pericardial rub in pericarditis varies widely among studies and is anywhere between 35% and 85%,[2][3][4] likely depending on the examiner's expertise, and the frequency of cardiac auscultation since the pericardial rub might variably be audible during the day.[5] It was initially thought to be due to the friction of two inflamed pericardium. However, this does not explain the presence of a rub in large pericardial effusions where the pericardial layers are not in contact. Moreover, the occurrence of the pericardial rub does not seem to be related to the size of the effusion; it was found present in 31 to 54% of small effusions, 43 to -55% of moderate effusions and 42 to 49% of large effusions (p-value greater than 0.05 in both studies).[2][6] Also, pericardial rub seems to be more detected in patients with acute pericarditis than in those with a chronic pericardial disease (74.4% versus 15.2%, p less than 0.001).[2] Thus, the theory of inflamed pericardial layers friction does not seem to explain the occurrence of a pericardial rub fully. Natan et al. hypothesized that the rub might be the result of the movement of fibrin strands caused by inflammation.[6]

Clinical Significance

The presence and documentation of a pericardial rub are of extreme importance since it is one of the four criteria to diagnose acute pericarditis. According to the 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases, acute pericarditis is diagnosable in the presence of two out of the four criteria: typical pericarditis chest pain, pericardial rub, diffuse ST-elevation or PR-depression on electrocardiogram and a new or worsening pericardial effusion.[7]

Thus, detection of pericardial rub along with a new pericardial effusion, for example, meets the criteria and the patient should be treated as acute pericarditis. An untreated episode of acute pericarditis increases the risk of complications including recurrent, chronic and constrictive pericarditis.

A pericardial rub can also be indicative of left ventricular dilation after acute Q-wave anterior myocardial infarction since transmural infarct can irritate the pericardium (and cause pericarditis) and cause left ventricular failure.[8] The presence of pericardial rub after Q-wave anterior myocardial infarction might also carry a worse prognosis and indicate extensive ventricular damage after coronary angioplasty.[9][10]

Nursing Actions and Interventions

Because of available technologies, expertise in bedside examination has declined among medical professionals. For every patient who presents with chest pain suspicious for acute pericarditis, the nursing and medical team should attentively try to identify a pericardial rub over the left sternal border at different times, since the presence of the rub is variable during the day. Its detection modifies the patient's management since the presence of a pericardial rub is very specific for acute pericarditis.

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Pericardial Friction Rub - Questions

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An 84-year male presents to the emergency department with chest pain that increases with a deep breath and bending forward. His past medical history is significant for hypertension and hyperlipidemia. He is a lifetime smoker and his current medications include amlodipine, statin, and a multivitamin. On arrival, his blood pressure is 129/80 and pulse is 101 bpm. The rest of his examination is unremarkable. According to the 2015 European Society of Cardiology Guidelines, which of the following (along with chest pain) can help diagnose acute pericarditis?

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Pericardial Friction Rub - References


Markiewicz W,Brik A,Brook G,Edoute Y,Monakier I,Markiewicz Y, Pericardial rub in pericardial effusion: lack of correlation with amount of fluid. Chest. 1980 May;     [PubMed]
Imazio M,Demichelis B,Parrini I,Giuggia M,Cecchi E,Gaschino G,Demarie D,Ghisio A,Trinchero R, Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. Journal of the American College of Cardiology. 2004 Mar 17;     [PubMed]
Zayas R,Anguita M,Torres F,Giménez D,Bergillos F,Ruiz M,Ciudad M,Gallardo A,Vallés F, Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The American journal of cardiology. 1995 Feb 15;     [PubMed]
Adler Y,Charron P,Imazio M,Badano L,Barón-Esquivias G,Bogaert J,Brucato A,Gueret P,Klingel K,Lionis C,Maisch B,Mayosi B,Pavie A,Ristic AD,Sabaté Tenas M,Seferovic P,Swedberg K,Tomkowski W, 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). European heart journal. 2015 Nov 7;     [PubMed]
Natan S,Lamfers EJ,Ophuis AJ,Meursing BT, Friction and fluid: correlating pericardial effusion and pericardial friction rub. Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation. 2001 Jun;     [PubMed]
Sugiura T,Iwasaka T,Yuasa F,Matsutani M,Tarumi N,Inada M, Clinical significance of pericardial rub with regional ventricular dilatation. Chest. 1991 Jul;     [PubMed]
Sugiura T,Iwasaka T,Takahashi N,Yuasa F,Tsuji H,Hasegawa T,Matsutani M,Inada M, Prognostic significance of hydropericardia and pericardial friction rub in Q-wave acute myocardial infarction. The American journal of cardiology. 1991 Mar 1;     [PubMed]
Sugiura T,Takehana K,Abe Y,Kamihata H,Karakawa M,Hatada K,Iwasaka T, Frequency of pericardial friction rub (     [PubMed]
Spodick DH, Pericardial rub. Prospective, Multiple observer investigation of pericardial friction in 100 patients. The American journal of cardiology. 1975 Mar;     [PubMed]
Spodick DH, Acute pericarditis: current concepts and practice. JAMA. 2003 Mar 5;     [PubMed]


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