Pericardial Disease

Question 1

What is the difference between acute pericarditis, Constrictive Pericarditis and Cardiac Tamponade?

Answer 1

Acute pericarditis = Inflammation of the pericardium

Constrictive Pericarditis = Fibrosing of the pericardium leading to the heart being encased in a rigid sac

Cardiac Tamponade = Increase in pericardial fluid -> Increase in intrapericardial pressure -> Lower ventricle filling and reduced Cardiac Output

Question 2

What causes acute pericarditis? [4]
List 2 types of infective causes
List 3 auto-immune causes of pericarditis

Answer 2

MI
Neoplastic
Radiation
Myxoedema
Infective
- Viral
- Bacterial eg TB
Autoimmune
- RA, SLE
- Scleroderma
- Dressler’s syndrome

Question 3

How does acute pericarditis present? [4]

Answer 3

Central Chest Pain [1] eased by leaning forward [1]
Pericardial Rub
~ Fever

Question 4

Acute pericarditis investigations [5]

When do we decide to admit?

Answer 4

• ECG - Saddle shaped (concave) ST elevation
• CXR - May show a pericardial effusion (follow with ECHO)
• Bloods - FBC, ESR, U+E, Cardiac enzymes e.g. troponin
• Blood cultures & Viral Serology

the majority of patients can be managed as outpatients
patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient

Question 5

How do we treat acute pericarditis? [2]

Answer 5

• strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
• a combination of NSAIDs and colchicine for idiopathic or viral pericarditis

Question 6

What causes constrictive pericarditis? [3]

Answer 6

Often unkown - TB - Post-pericarditis

Question 7

How does constrictive pericarditis present?
Symptoms [3]
Signs [3]

Answer 7

Fatigue
 - Dyspnoea 
- weakness 
- Peripheral Oedema (symptoms of RHF)
Raised JVP on inspiration (Kussmaul's signs) 
- Ascites (abdominal swelling) 
- quiet heart sounds

Question 8

How do we test for constrictive pericarditis? [4]

Answer 8

ECG - low voltage complexes
CXR = May see small heart and calcification
CT/MRI - IF CXR unclear
ECHO
Cardiac Catheterization

Question 9

How do we treat constrictive pericarditis? [1]

Answer 9

Surgical Excision

Question 10

What causes cardiac tamponade? [3]

Answer 10

Any pericarditis
Aortic Dissection
Warfarin

Question 11

How does cardiac tamponade present?
Symptoms [4]
Signs [3]

Answer 11

Cardiogenic Shock:

• Dizziness
• Weakness/collapse
• Dyspnoea, Cough
• Central Chest Pain

Becks Triad: 
- muffled Heart Sounds
- Raised JVP 
- drop in BP, increase HR
Pulsus paradoxus
Kussmaul breathing

Question 12

How do we diagnose Cardiac Tamponade? [4]

Describe what you might see that would confirm the diagnosis

Answer 12

CXR: Over 250ml will show a big globular heart
ECG: Low voltage QRS complexes, QRS alternans
ECHO: Larger pericardium +/- collapsed ventricles (mainly right heart in diastole)
Aspirate some fluid and send for M,C & S

Question 13

How do we treat Cardiac Tamponade? [4]

Answer 13

Treat the cause
URGENT drainage of the fluid (pericardiocentesis
Percutaneous balloon pericardiotomy
Pericardial resection

Question 14

Restrictive cardiomyopathy

Answer 14

• amyloidosis (e.g. secondary to myeloma) - most common cause in UK
• haemochromatosis
• post-radiation fibrosis
• Loffler’s syndrome: endomyocardial fibrosis with a prominent eosinophilic infiltrate
• endocardial fibroelastosis: thick fibroelastic tissue forms in the endocardium; most commonly seen in young children
• sarcoidosis
• scleroderma

Question 15

What features suggest restrictive cardiomyopathy rather than constrictive pericarditis

Answer 15

• prominent apical pulse
• absence of pericardial calcification on CXR
• the heart may be enlarged
• ECG abnormalities e.g. bundle branch block, Q waves