Acute and Chronic Pericarditis

Question 1

Aetiology and pathophysiology of Pericarditis

Answer 1

-Idiopathic
-Infection (acute viral Coxsackie B, TB, bacterial pneumonia)
-Post-myocardial infarction (early 1-3 days: fibrinous/ late weeks to months: autoimmune or Dressler’s syndrome)
-Iatrogenic (pacemaker, PCI, radiotherapy)
-Autoimmune (systemic sclerosis, lupus, RA, hypothyroidism)
-Neoplastic (metastatic from breast cancer, lung cancer, lymphoma)
-Metabolic (uraemia, anorexia, myxoedema)
-Trauma

Question 2

Definition of acute pericarditis

Answer 2

Acute pericarditis is a condition referring to inflammation of the pericardial sac, lasting for less than 4-6 weeks.

Question 3

Symptoms of pericarditis

Answer 3

-Sharp central chest pain
=Accentuated lying supine, relieved sitting upright and forwards
=Exacerbated by deep inspiration or coughing
-May be accompanied by fever, palpitation, dyspnoea
-Other symptoms consistent with aetiology (rheumatic in connective tissue disease)
-other symptoms include a non-productive cough, dyspnoea and flu-like symptoms

Question 4

Clinical signs of pericarditis

Answer 4

-Fever
-Pericardial rub (biphasic scratching sound, systole, lying supine)
-Pulsus paradoxus
-Beck’s triad -tamponade: muffled heart sounds, hypotension, elevated JVP

Question 5

Investigations of pericarditis

Answer 5

-ECG: PR depression (most specific), widespread concave/ saddle shaped ST elevation, T wave changes
-Blood panel: FBC, UEs, CRP/ESR (inflammatory, metabolic disturbance), troponin (myocarditis)
-CXR (pericardial effusion)
-Consider echocardiogram ALL transthoracic
-Consider CT/MRI in refractory pericarditis
-Inflammatory markers, troponin (30% elevated)

Question 6

Treatment of pericarditis

Answer 6

-NSAIDs: until symptom resolution and normalisation of inflammatory markers (usually 1-2 weeks) followed by tapering of dose recommended over
-Colchicine (consider prolonged course)
-Exercise restriction
-Corticosteroids (autoimmune, relapsing)
-Pericardiocentesis (tamponade, neoplastic or infective aetiology)
-Treatment directed toward aetiology

patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient

Question 7

Prognosis and long-term care of pericarditis

Answer 7

-Serious complications rare (e.g., tamponade)
-Recurrent pericarditis in 1 in 4
-Chronic recurrent pattern rare
-Constrictive pericarditis rare (most often in suppurative pericarditis)

Question 8

Causes and features of constrictive pericarditis

Answer 8

Causes
any cause of pericarditis
particularly TB

Features
dyspnoea
right heart failure: elevated JVP, ascites, oedema, hepatomegaly
JVP shows prominent x and y descent
pericardial knock - loud S3
Kussmaul’s sign is positive

Question 9

Investigation of constrictive pericarditis

Answer 9

CXR
pericardial calcification

Question 10

Constrictive pericarditis vs cardiac tamponade

Answer 10

-CP:
=X + Y JVP
=Absent pulsus paradoxus
=Kussmaul’s sign (paradoxical rise in JVP during inspiration)
=Pericardial calcification on CXR

-CT:
=Absent Y descent JVP
=Pulsus paradoxus
=Kussmaul’s sign rare

A commonly used mnemonic to remember the absent Y descent in cardiac tamponade is TAMponade = TAMpaX