4. Pericarditis Flashcards
How much serous fluid is there between the visceral and parietal pericardium?
50ml.
What is the function of the serous fluid between the visceral and parietal pericardium?
It acts as a lubricant and so allows smooth movement of the heart inside the pericardium.
What is the function of pericardium?
It restrains the filling volume of the heart.
Why does chronic pericardial effusion rarely cause tamponade?
Chronic accumulation of effusions slowly -> parietal pericardium adapts.
Reduces the effect on diastolic filling of the heart chambers.
And so tamponade is prevented.
What is acute pericarditis?
An inflammatory pericardial syndrome with or without effusion.
How can acute pericarditis be clinically diagnosed?
Acute pericarditis can be clinically diagnosed if the patient has at least 2 of the following:
- Chest pain.
- Friction rub.
- ECG changes.
- Pericardial effusion.
Describe the aetiology of pericarditis.
- Viral (common) e.g. enteroviruses.
- Bacterial e.g. mycobacterium tuberculosis.
- Autoimmune e.g. RA, sjögren syndrome.
- Neoplastic.
- Metabolic e.g. uraemia.
- Traumatic and iatrogenic.
- 80-90% are idiopathic.
List 3 viral causes of acute pericarditis.
Enteroviruses e.g. Coxsackie B
Herpesviruses e.g. EBV, HHV-6
Mumps
HIV
Adenoviruses
Parvovirus B19 (possible overlap with aetiologic viral agents of myocarditis)
List 3 bacterial causes of acute pericarditis.
Pneumonia
Rheumatic fever
TB - Mycobacterium tuberculosis
Streps
Staphs
List 5 causes, other than bacterial/viral infection, of acute pericarditis.
Fungi, MI, uraemia, rheumatoid arthritis, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy, sarcoidosis, idiopathic + drugs
Give 5 symptoms of pericarditis.
- Chest pain! Described as severe, sharp and pleuritic. Rapid onset. Pain can radiate to the arm.
- Dyspnoea.
- Cough.
- Hiccups.
- Skin rash.
Describe the chest pain symptom of pericarditis.
- Severe, sharp and pleuritic
- Rapid onset.
- Left anterior chest
- Pain radiates to the arm, more specifically the trapezius ridge
- Relieved by sitting forward BUT exacerbated by lying down
Why might someone with pericarditis have hiccups?
Because of irritation to the phrenic nerve.
What investigations might you do on someone who you suspect to have pericarditis?
- Clinical examination
- ECG.
- CXR.
- Bloods.
- Echocardiogram.
What might be found in the blood tests for acute pericarditis?
- FBC
- Modest increase in WCC (white blood cell count) - ESR + CRP
- High ESR
- ANA (antinuclear antibodies) in young females -> SLE - Troponin
- Elevations -> suggest myopercarditis - CXR
- Often normal in idiopathic
- Pneumonia common with bacterial causes
What might the ECG look like in someone with acute pericarditis?
- PR depression seen in most leads.
- ‘Saddle shaped’ concave ST elevation.
What might be observed/found upon clinical examination for acute pericarditis?
- Pericardial rub
- Sinus tachycardia
- Fever
- Signs of effusion (pulsus paradoxus, Kussmaul’s sign)
What might be heard on auscultation of a patient with pericarditis?
Pericardial friction rub
What is the major differential diagnosis of acute pericarditis?
MI - it is important to rule this out ASAP!
What is the treatment for pericarditis?
- Patients are advised to avoid strenuous activity until symptom resolution - sedentary activity advised - until symptoms die down and ECG/CRP
- NSAID (e.g. ibuprofen) or aspirin -> high doses.
- Colchicine (anti-inflammatory)
What is constrictive pericarditis?
Heart is encased in a rigid fibrotic pericardium - prevents diastolic filling of ventricles.
What causes constrictive pericarditis?
Most common in UK = idiopathic.
Globally = TB.
Also occurs after any pericarditis.
What are the clinical features of constrictive pericarditis?
Those of right-sided heart failure - raised JVP, oedema, hepatomegaly, ascites, pulsus paradoxus, diffuse apex beat
What 2 investigations would you carry out in constrictive pericarditis and what would you find?
- CXR - normal/small heart + pericardial calcification.
- CT/MRI - pericardial thickening/calcification
How would you treat constrictive pericarditis?
Surgical excision of pericardium
What is Dressler’s syndrome?
Myocardial injury stimulates formation of autoantibodies against the heart. Cardiac tamponade may occur. Dressler’s is a secondary form of pericarditis.
What coronary event might Dressler’s syndrome develop after?
Can develop 2-10 weeks after an MI.
