Pericardial disease

Question 1

Acute pericarditis causes

Answer 1

Idiopathic
Infection (TB commonest cause worldwide)
Autoimmune
Drugs (procainamide, hydralazine, penicillin, isoniazid)
Metabolic (uraemia, hypothyroidism, anorexia)
Trauma
MI

Question 2

Acute pericarditis presentation

Answer 2

Central chest pain worse on inspiration/ lying flat ± relief by sitting forward
Pericardial friction rub may be heard
Evidence of pericardial effusion/ cardiac tamponade
Fever

Question 3

Acute pericarditis tests

Answer 3

ECG classically shows concave saddle shaped ST elevation + PR depression but may be normal
Troponin may be raised
CXR cardiomegaly if effusion

Question 4

Acute pericarditis treatment

Answer 4

Rest
Treat cause

NSAIDs/ aspirin with gastric protection for 1-2wks
Colchicine 500µg OD/BD for 3mths to reduce recurrence
Steroids/immunosuppressants if refractory autoimmune

Question 5

What is pericardial effusion

Answer 5

Accumulation of fluid in pericardial sac (10-50ml)

Question 6

Pericardial effusion causes

Answer 6

Pericarditis
Myocardial rupture e.g. in stab wound or post MI
Aortic dissection
Malignancy

Question 7

Pericardial effusion presentation

Answer 7

Dyspnoea
Chest pain
Compression of phrenic n (hiccups), diaphragm (nausea)
Muffled heart sounds
Cardiac tamponade signs

Question 8

Pericardial effusion diagnosis

Answer 8

CXR shows enlarged heart if effusion >300ml
ECG shows low voltage QRS
Echo shows echo-free zone surrounding heart

Question 9

Pericardial effusion management

Answer 9

Treat cause
Pericardiocentesis can be diagnostic of bacteria or therapeutic for tamponade
Send pericardial fluid for culture

Question 10

Constrictive pericarditis causes

Answer 10

Unknown (UK most common)
TB (everywhere else common)
Post-pericarditis

Question 11

Constrictive pericarditis presentation

Answer 11

Mainly RHF with inc JVP
Kussmaul’s sign (JVP rises paradoxically with inspiration)
Quiet heart sounds
Hepatomegaly

Question 12

Constrictive pericarditis investigations

Answer 12

CXR shows small heart ± pericardial calcification

CT/MRI distinguishes from restrictive cardiomyopathy

Question 13

What is cardiac tamponade

Answer 13

Pericardial effusion that raises intrapericardial pressure, reducing ventricular filling so dropping CO
Can rapidly lead to cardiac arrest

Question 14

Cardiac tamponade signs

Answer 14

Inc pulse
Dec BP
Pulsus paradoxus
Kussmaul's sign
Raised JVP
Muffled S1 + S2

Question 15

Cardiac tamponade diagnosis

Answer 15

Beck’s triad: falling BP, rising JVP, muffled heart sounds
ECG shows low voltage QRS
Echo is diagnostic (echo-free zone around heart is >2cm or >1 if acute) ± diastolic collapse of RA + RV

Question 16

Cardiac tamponade management

Answer 16

Expert help
Pericardial drainage
Culture fluid

Question 17

Constrictive pericarditis management

Answer 17

Surgical excision

Medical treatments for cause/symptoms