Pericardial disease

Question 1

Acute pericarditis is inflammation of the pericardium. Causes are either idiopathic or secondary.

What are the secondary causes of acute pericarditis?

Answer 1

• Viruses → coxsackie / echovirus / EBV / CMV / adenovirus / mumps / varicella / HIV
• Bacteria → TB / lyme / pneumonia / rheumatic fever / staphs / streps / legionella
• Autoimmune → SLE / RA / IBD / sarcoid / amyloid / Dressler’s
• Drugs → procainamide / hydralazine / isoniazid / chemo
• Metabolic → uraemia / hypothyroid / anorexia nervosa

Question 2

What are the clinical features of acute pericarditis?

Answer 2

• Central chest pain worse on inspiration or lying flat
• Relief by sitting forwards
• Pericardial friction rub may be heard
• Look for evidence of pericardial effusion or tamponade
• Fever may occur

Question 3

What investigations can be done for acute pericarditis?

Answer 3

• ECG → concave, wide-spread saddle-shaped ST elevation and PR depression, may be normal or non-specific
• Bloods → relating to possible aetiologies
• CXR → cardiomegaly ?pericardial effusion → further Ix w/ echo

Question 4

What is the treatment of acute pericarditis?

Answer 4

• NSAIDs or aspirin + gastroprotection 1-2 weeks
• Add colchicine 500mcg OD or BD for 3 months to reduce risk of recurrence
• Treat cause; if not improving or autoimmune disorder, consider steroids
• Rest until symptoms resolve

Question 5

What is Dressler’s syndrome?

Answer 5

• Pericarditis observed 2-4wks post-MI
• Unique autoimmune mediated phenomenon to myocardial antigens
• Features → fever, pleuritic pain, pericardial effusion + raised ESR
• Tx → NSAIDs

Question 6

What is a pericardial effusion?

Answer 6

• Accumulated fluid in pericardial sac (~ 10-50mL)
• Causes → pericarditis, myocardial rupture, dissection, malignancy

Question 7

What are clinical features of pericardial effusion?

Answer 7

• Dyspnoea
• Chest pain
• Signs of local structures being compressed → hiccups, nausea, bronchial breathing at left base
• Muffled heart sounds

Always look for signs of cardiac tamponade

Question 8

Which investigations are done for pericardial effusion?

Answer 8

• CXR → enalarged, globular heart if effusion > 300mL
• ECG → low-voltage QRS complexes + may have alternating QRS morphologies (electrical alternans)
• Echo → shows echo-free zone surrounding heart

Question 9

What is the management of pericardial effusion?

Answer 9

Treat cause. Pericardiocentesis may be:

• diagnostic → suspected bacterial pericarditis
• therapeutic → cardiac tamponade

Send pericardial fluid for culture, ZN stain/TB culture and cytology

Question 10

What is constrictive pericarditis?

Answer 10

• Heart encased in a rigid pericardium
• Causes → often unknown / TB / post-pericarditis

Question 11

What are clinical features of constrictive pericarditis?

Answer 11

• Increased JVP (prominent X + Y descents)
• Kussmaul’s sign (JVP paradoxically rising with inspiration, in normal inspiration JVP falls)
• Soft, diffuse apex beat
• Quiet heart sounds
• Diastolic pericardial knock
• Hepatosplenomegaly
• Ascites
• Oedema

Mimics RHF

Question 12

Which investigations are done for constrictive pericarditis?

Answer 12

• CXR → small heart +/- pericardial calcification
• CT/MRI → helps distinguish from restrictive cardiomyopathy

Question 13

What is the management of constrictive pericarditis?

Answer 13

• Surgical excision alongside medical treatment to address cause and symptoms