Acute Pericarditis

Question 1

ESSENCE

Answer 1

Inflammation of the pericardium characterised by sharp pain on inhalation

Question 2

AETIOLOGY

Common causes

Answer 2

• Idiopathic most common
• Viral infections
  
  • Eg coxsackie A9 or B1-4 echovirus, mumps, EBV, cytomegalovirus, varicella, rubella, HIB, parovirus
• Systemic autoimmune disorders
  
  • Eg RA, systemic sclerosis, IBD, systemic vasculitides
• Secondary causes
  
  • Rheumatic fever, post-MI

Question 3

PROGNOSIS

General

Answer 3

Can be acute or chronic and may recur

Question 4

PATHOGENESIS

Answer 4

• Inflammation of pericardium can cause chest pain
• Movement of heart can cause friction between 2 pericardial layers, producing friction rub
• Inflammation may cause pericardial effusion

Question 5

CLINICAL FEATURES

Presentation

Answer 5

• Sharp pleuritic chest pain worse by inhalation
  
  • Maybe refers to shoulder
• Fever (uncommon)

Question 6

CLINICAL FEATURES

Signs

Answer 6

• Friction rub
• Kussmaul sign (in contrictive pericarditis)
  
  • Increased jugular venous distention on inspiration

Question 7

INVESTIGATIONS

First choice

Answer 7

• Imaging
  
  • Echocardiography - assess for effusion and cardiac tamponade
  • X-ray - rule out pneumonia
• ECG
• Labs
  
  • ESR - increased
  • CRP - increased
  • Troponin - may be increased

Question 8

INVESTIGATIONS

How is diagnosis made

Answer 8

Clinical findings and ECG

Question 9

INVESTIGATIONS

What is seen on ECG

Answer 9

• PR segment depression, especially lead II and all leads except aVR
• Widespread ST segment elevation
• Upright T waves

Question 10

MANAGEMENT

General principles

Answer 10

• Observation and treatment of underlying cause if asymptomatic or small
• Pericardiocentesis if large or cardiac tamponade
• Operative pericardiectomy for recurrent disease

Question 11

MANAGEMENT

Medical options

Answer 11

• NSAIDs for viral
• Steroids and immunosuppresants for SLE
• Dialysis for uraemia
• Aspirin for post-MI

Question 12

MANAGEMENT

Lines for recurrent

Answer 12

• 1) NSAID
  
  • Plus PPI (because of high dose NSAID)
  • Plus colchicine
  • Plus treatment underlying cause
  • Plus exercise restriction
  • Adjunct corticosteroid
  • Adjunct imunnosuppresant
  • Adjunct pericardectomy

Question 13

First line NSAID

Answer 13

Aspirin or ibuprofen

Question 14

First line PPI

Answer 14

Omeprazole

Question 15

Why is colchicine used

Answer 15

Crucial to reduce recurrences, improve response and increased remission rate

Question 16

When should colchicine not be used

Answer 16

In TB pericarditis

Question 17

When is corticosteroid considered

Answer 17

Patient doesnt respond to NSAID plus colchicine, only use if infection has been excluded

Question 18

First line corticosteroid

Answer 18

Prednisolone

Question 19

First line immunosuppresant options

Answer 19

Azathioprine

or Anakinra

or normal immunoglobulin human

Question 20

When is pericardectomy indicated

Answer 20

• TB pericarditis with recurrent effusions
  
  • Patients condition not improving or deteriorating after 4-8 weeks TB therapy
• Or evidence constrictive physiology despire medical therapy

Question 21

COMPLICATIONS

Answer 21

• Pericardial effusion with or without cardiac tamponade