Pericardial disease

Question 1

What is pericarditis?

Answer 1

• Pericarditis → inflammation of the pericardium (outer sac) that may be acute or chronic

Question 2

Summarise the epidemiology of pericarditis

Answer 2

● UNCOMMON
● < 1/100 hospital admissions
● More common in males

Question 3

What causes pericarditis?

Answer 3

1. IDIOPATHIC
2. Infective
   Most common causative organisms:
   o Coxsackie B
   o Echovirus
   o Mumps
   o Streptococci
   o Fungi
   o Staphylococci
   o TB
3. Connective tissue disease (e.g. sarcoidosis, SLE, scleroderma)
4. Post-MI (within 24-72 hrs of MI - occurs in up to 20% of patients)
5. Dressler’s Syndrome - pericarditis occurring weeks/months after acute MI
6. Malignancy - lung, breast, lymphoma, leukaemia, melanoma
7. Radiotherapy
8. Thoracic surgery
9. Drugs (e.g. hydralazine, isoniazid)
10. Others: uraemia, rheumatoid arthritis, myxoedema, trauma

Question 4

What are the presenting symptoms of pericarditis?

Answer 4

1. CHEST PAIN
   o Sharp and central
   o May be stabbing or aching
   o May radiate to the neck or shoulders (typically left side)
   o Worse when coughing and deep inspiration (pleuritic pain)
   o Relieved by sitting forward
   o Worse when lying flat
2. Dyspnoea
3. Nausea

Question 5

What signs of pericarditis can be found on physical examination?

Answer 5

1. Fever & myalgia
2. Pericardial friction rub
   o Heard best at lower left sternal edge, with patient leaning forward during expiration. Sounds like leather rubbing against each other
3. Heart sounds may be faint due to a pericardial effusion
4. Cardiac Tamponade signs (when fluid in the pericardium builds up resulting in compression of the heart)
   a. Beck’s Triad (signs associated with acute cardiac tamponade)
   ● Raised JVP
   ● Low Blood Pressure
   ● Muffled Heart Sounds
   b. Tachycardia
   c. Pulsus paradoxus
   ● Definition: an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration

Question 6

What investigations are used to diagnose/ manage pericarditis?

Answer 6

1. ECG→ saddle shaped ST elevation (IN ALL LEADS) + PR depression 
2. Transthoracic Echocardiography → pericardial effusion (cardiac tamponade) may be present
3. CXR → May be globular if there is a pericardial effusion
4. Troponin → elevation indicates myopericarditis or other aetiologies such as ACS
5. U&Es → elevated urea suggests a uraemic cause
6. Blood Culture → positive if infective cause

Question 7

How is pericarditis managed?

Answer 7

1. Often self-limiting → NSAIDs can help alleviate symptoms (Aspirin, Ibruprofen) (Can also give PPI prophylaxis to protect against effects of high doses of NSAIDs) + bed rest
2. If the patient has idiopathic or viral pericarditis, add Colchicine and continue it for 3 months.
   - Main side effect is diarrhoea
3. Surgical:
   - If Tamponade → Pericardiocentesis-also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium
   - If Recurrent → Pericardiectomy (complete removal of the pericardium)

Question 8

Describe the prognosis of pericarditis

Answer 8

● Depends on the underlying cause
● Viral cases have a GOOD prognosis
● Malignant pericarditis has a POOR prognosis
● 15-40% recur

Question 9

What complications may arise from pericarditis?

Answer 9

● Pericardial effusion – pooling of fluid in pericardial space
● Cardiac tamponade – a large pericardial effusion can put pressure on the heart
● Cardiac arrhythmias

Question 10

What signs on physical examination can make you suspect constrictive pericarditis?

Answer 10

o Kussmaul’s sign
o Pulsus paradoxus
o Hepatomegaly
o Ascites
o Oedema
o Pericardial knock (due to rapid ventricular filling) – early diastolic sound
o AF

Question 11

What are the 2 types of pericarditis you can have?

Answer 11

1. Acute → new-onset inflammation lasting <4 to 6 weeks. Most commonly caused by a viral infection.
2. Chronic Pericarditis → lasts >3 months. Leads to constrictive pericarditis