Acute and chronic pericarditis, pericardial effusion and cardiac tamponade Flashcards
What is the anatomy of the pericardium? [8]
- the pericardium acts as a protective covering for the heart
- outer fibrous pericardial sac
- inner serous pericardium -
- outer parietal pericardium
- inner visceral pericardium (epicardium) lines the outer surface of the heart
- pericardial space between the two layers
- great vessels also lie within the pericardium
- left atrium is mainly outside the pericardium
What happens if fluid enters the pericardial space? [2]
- at low tension, the pericardium has a small reserve volume
- if this volume is exceeded there is an increase in intrapericardial pressure on the heart (e.g. cardiac tamponade)
What is the definition of acute pericarditis? [1]
acute inflammation of the pericarditis +/- pericardial effusion
What is the aetiology of acute pericarditis? [6]
- majority of cases are idiopathic
- viruses - enteroviruses - coxsachieviruses and echoviruses, adenoviruses
- bacteria - TB, pneumonia, rheumatic fever
- fungi and parasites
- autoimmune - rheumatoid arthritis
- other - iatrogenic (surgery, radiotherapy, drugs), trauma, malignancy
What is the clinical presentation of acute pericarditis? [7]
- chest pain - severe, sharp and pleuritic (without constriction/crushing character), worse on inspiration or lying flat
- dyspnoea
- cough
- hiccups due to involvement of phrenic nerve
- pericardial friction rub on auscultation
- fever
- tachycardia
What is the differential diagnosis of acute pericarditis? [8]
- pulmonary infarction
- pneumonia
- pleuritic pain
- peritonitis
- GI reflux
- angina
- aortic dissection
- myocardial infarction
How can acute pericarditis be diagnosed? [3]
- ECG - concave, saddle-shaped ST elevation present in all leads, with PR depression
- chest x-ray - cardiomegaly may indicate pericardial effusion, pneumonia
- blood tests - slight increase in white cell count, elevated troponin suggests myopericarditis
What is the treatment of acute pericarditis? [3]
- restricted physical activity until resolution of symptoms/improvement seen on ECG
- NSAIDs (e.g. ibuprofen) or aspirin for 2 weeks
- Colchicine which treats inflammation and pain and prevents pericarditis, for 3 weeks (not well tolerated due to nausea and diarrhoea)
What is recurrent/relapsing pericarditis? [4]
- about 20% of cases go on to develop idiopathic relapsing pericarditis
- first line of treatments is NSAIDs
- colchicine also given, more effective than aspirin
- could go on to develop constrictive pericarditis; thickened and calcified pericardium
What is the definition of pericardial effusion? [2]
- accumulation of fluid in the pericardial space
2. when large volume collects and ventricular filling is compromised, leads to cardiac tamponade
What is the clinical presentation of pericardial effusion? [5]
- symptoms commonly reflect the underlying pericarditis
- soft and distant heart sounds
- apex beat obscured
- increased jugular venous pressure
- dysnpnoea
How can pericardial effusion be diagnosed? [3]
- chest x-ray - enlarged globular heart
- ECG - low voltage QRS complexes, sinus tachycardia
- echocardiogram - echo-free zone surrounding heart
What is the treatment of pericardial effusion? [3]
- underlying cause treated if possible
- most pericardial effusions resolve spontaneously
- pericardiocentesis may be diagnostic - drainage of pericardial fluid and sent for culture
What is the definition of cardiac tamponade? [2]
- a pericardial effusion that raises intrapericardial pressure, reducing ventricular filling and thus dropping cardiac output
- can lead rapidly to cardiac arrest so urgent treatment needed
What happens in chronic pericardial effusion? [2]
- slow accumulation of fluid allows the pericardium to adapt slowly
- so there is much slower tamponade with no collapse of the right atrium
What is the clinical presentation of cardiac tamponade? [5]
- increased pulse but decrease blood pressure
- increased jugular venous pressure
- pulsus paradoxus - decreased stroke volume and systolic blood pressure during inspiration
- Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inspiration
- muffled 1st and 2nd heart sounds
How can cardiac tamponade be diagnosed? [4]
- chest x-ray - enlarged globular heart
- ECG - low voltage QRS complexes
- echocardiogram - diagnostic, echo-free zone surrounding heart AND diastolic collapse of right atrium and ventricle
- Beck’s triad - low blood pressure, increased jugular venous pressure, and muffled heart sounds
What is the treatment of cardiac tamponade? [3]
- seek expert help
- urgent drainage of pericardial fluid required - pericardiocentesis to relieve pressure on the heart
- send fluid for culture, Ziehl-Neelsen stain, and cytology
What is the definition of constrictive pericarditis? [3]
- the heart is encased in rigid pericardium (calcified)
- interferes with the diastolic filling of the heart
- cause is often idiopathic, TB or any pericarditis
What is the clinical presentation of constrictive pericarditis? [7]
- increased jugular venous pressure
- Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inhalation
- pulsus paradoxus - large decrease in stroke volume and systolic blood pressure during inspiration
- quiet heart sounds
- soft, diffuse apex beat
- oedema
- ascites
What is the diagnosis of constrictive pericarditis? [4]
- chest x-ray - small heart +/- pericardial calcification
- ECG - low voltage QRS complexes
- echocardiogram - thickened, calcified pericardium, small ventricular cavities with normal wall thickness
- CT/MRI - constrictive pericarditis should be distinguished from restrictive cardiomyopathy
What is the treatment of constrictive pericarditis? [1]
complete resection/surgical excision of pericardium; high complication rate
