Acute Pericarditis Flashcards
ESSENCE
Inflammation of the pericardium characterised by sharp pain on inhalation
AETIOLOGY
Common causes
- 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
PROGNOSIS
General
Can be acute or chronic and may recur
PATHOGENESIS
- 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
CLINICAL FEATURES
Presentation
- Sharp pleuritic chest pain worse by inhalation
- Maybe refers to shoulder
- Fever (uncommon)
CLINICAL FEATURES
Signs
- Friction rub
- Kussmaul sign (in contrictive pericarditis)
- Increased jugular venous distention on inspiration
INVESTIGATIONS
First choice
- Imaging
- Echocardiography - assess for effusion and cardiac tamponade
- X-ray - rule out pneumonia
- ECG
- Labs
- ESR - increased
- CRP - increased
- Troponin - may be increased
INVESTIGATIONS
How is diagnosis made
Clinical findings and ECG
INVESTIGATIONS
What is seen on ECG
- PR segment depression, especially lead II and all leads except aVR
- Widespread ST segment elevation
- Upright T waves
MANAGEMENT
General principles
- Observation and treatment of underlying cause if asymptomatic or small
- Pericardiocentesis if large or cardiac tamponade
- Operative pericardiectomy for recurrent disease
MANAGEMENT
Medical options
- NSAIDs for viral
- Steroids and immunosuppresants for SLE
- Dialysis for uraemia
- Aspirin for post-MI
MANAGEMENT
Lines for recurrent
- 1) NSAID
- Plus PPI (because of high dose NSAID)
- Plus colchicine
- Plus treatment underlying cause
- Plus exercise restriction
- Adjunct corticosteroid
- Adjunct imunnosuppresant
- Adjunct pericardectomy
First line NSAID
Aspirin or ibuprofen
First line PPI
Omeprazole
Why is colchicine used
Crucial to reduce recurrences, improve response and increased remission rate
When should colchicine not be used
In TB pericarditis
When is corticosteroid considered
Patient doesnt respond to NSAID plus colchicine, only use if infection has been excluded
First line corticosteroid
Prednisolone
First line immunosuppresant options
Azathioprine
or Anakinra
or normal immunoglobulin human
When is pericardectomy indicated
- TB pericarditis with recurrent effusions
- Patients condition not improving or deteriorating after 4-8 weeks TB therapy
- Or evidence constrictive physiology despire medical therapy
COMPLICATIONS
- Pericardial effusion with or without cardiac tamponade
