Pericardial disease (CV) Flashcards
Define pericarditis.
Inflammation of the pericardium (outer sac) - may be acute or chronic
What is acute pericarditis?
New-onset pericardial inflammation lasting <4 to 6 weeks
What is acute pericarditis commonly caused by?
Viral infection
What is chronic pericarditis?
Lasts >3 months
What does chronic pericarditis lead to?
Constrictive pericarditis - impedes normal diastolic filling
When can constrictive pericarditis be caused? (2)
- chronic pericarditis leads to constrictive pericarditis
- medium to late complication of acute pericarditis
What are the clinical features of constrictive pericarditis? (4)
- dyspnoea
- right heart failure - peripheral oedema
- Kussmaul’s sign - paradoxical rise in JVP on inspiration, caused by impaired filling of RV due to poorly compliant myocardium/pericardium (JVP should normally fall with inspiration due to reducing pressure in thoracic cavity)
- pulsus paradoxus (sign of tamponade but also seen here) - SBP falls >10 on inspiration
What are the signs of constrictive pericarditis? (7)
- Kussmaul’s sign (paradoxical rise in JVP on inspiration)
- pulsus paradoxus
- peripheral oedema
- ascites
- hepatomegaly
- pericardial knock (rapid ventricular filling) - early diastolic sound
- atrial fibrillation
What does Kussmaul’s sign help us differentiate between (pericarditis)?
Constrictive pericarditis (due to chronic pericarditis) and cardiac tamponade - sign not present in tamponade
Cardiac tamponade = fluid in pericardial sac
What might a CXR show in constrictive pericarditis?
Pericardial calcification
Which groups does pericarditis affect most? (2)
- M>F
- most common in 20-50 year olds
What is the aetiology of pericarditis?
Idiopathic
What is Dressler’s syndrome?
Pericarditis several weeks/months after an MI, that may occur with/without effusion
What are the features of Dressler’s syndrome (pericarditis)? (4)
- acute pleuritic chest pain
- fever
- raised ESR
- SOB worse when lying down and better when sitting forward
What would you see on ECG in Dressler’s syndrome (pericarditis)? (3)
- widespread concave ST elevation
- PR depression with reciprocal ST depression
- PR elevation in aVR
How is Dressler’s syndrome (pericarditis) treated? (2)
- NSAIDs preferably
- prolonged course of colchicine or steroids
What are the clinical features of pericarditis? (4 + 8)
- chest pain
- pleuritic
- sharp
- acute
- severe
- central
- radiates to neck/shoulders on LHS
- worse when lying flat, coughing, deep inspiration
- relieved by leaning forward/sitting up
- fever
- myalgia
- dyspnoea
What might you see on examination of pericarditis? (4)
- pericardial friction rub - superficial scratchy/squeak sound over lower left sternal border, patient leaning forward at end expiration (sounds like leather rubbing against each other)
- fever
- faint heart sounds (due to pericardial effusion)
- cardiac tamponade signs (fluid build-up in pericardium and constricts heart)
What is cardiac tamponade (pericarditis complication)?
Fluid accumulates in pericardial space and constricts the heart, preventing effective contraction –> cardiogenic shock
What are the features of cardiac tamponade (pericarditis complication)? (2)
- Beck’s triad - raised JVP, decreased BP, muffled heart sounds
- pulsus paradoxus - large drop in BP during inspiration
- (to distinguish - pericarditis has Kussmaul’s sign)
What triad is seen in cardiac tamponade (pericarditis)?
Beck’s triad:
- raised JVP
- decreased BP
- muffled heart sounds
What investigation is diagnostic for cardiac tamponade and what would you see?
ECG showing electrical alternans (different sized QRS complexes)
What triad is seen in pericarditis?
- chest pain - sharp, reverse, retrosternal, worse on inspiration/supine
- pericardial friction rub
- serial electrocardiographic changes
How can we differentiate pericarditis from myocarditis?
Myocarditis has acute pulmonary oedema
What are some risk factors for pericarditis? (10)
- M>F
- 20-50y
- transmural MI
- cardiac surgery
- infection (Coxsackie B, Hx of cold/flu Sx)
- connective tissue disease (sarcoidosis, SLE, scleroderma)
- malignancy
- uraemia
- systemic autoimmune disorders (RA, SLE)
- other causes - radiotherapy, thoracic surgery, drugs, Behcet’s syndrome, trauma
What are the first-line investigations for pericarditis? (4)
- ECG
- serum troponin
- pericardiocentesis
- CRP
What scans do we do in pericarditis? (3)
- ECG
- transthoracic echocardiography - pericardial effusion, cardiac tamponade may be present
- CXR - pericardial effusion (globular)
What would ECG show in pericarditis? (3)
- widespread saddle-shaped ST elevation in all leads with no reciprocal changes
- PR depression (later followed by T-wave flattening and inversion)
- tachycardia
What does serum troponin show in pericarditis?
Elevated indicates myopericarditis or other aetiologies such as ACS
What does elevated urea indicate in pericarditis?
Uraemic cause
When do you do pericardiocentesis in pericarditis?
If you suspect cardiac tamponade, do urgent pericardiocentesis and send pericardial fluid for analysis
- acid-fast bacilli, positive culture of Mycobacterium tuberculosis
- transudate or exudate
Why would you do a blood culture in pericarditis?
Positive if infective cause
What are some differential diagnoses for pericarditis? (5)
- pulmonary embolism
- MI or ischaemia
- pneumonia
- pneumothorax
- costochondritis
What is the diagnostic criteria for acute pericarditis (new onset, <4-6 weeks)?
Inflammatory pericardial syndrome associated with 2+ of the following 4 criteria:
- characteristic chest pain - typically sharp, pleuritic, and relieved by sitting forwards
- pericardial friction rub
- new widespread diffuse concave upwards ST elevation and/or PR depression on ECG
- new or worsening pericardial effusion
What is the diagnostic criteria for chronic pericarditis?
Signs and symptoms persisting for >3 months
What are some subtypes of pericarditis? (3)
- constrictive: due to chronically thickened pericardium
- effusive-constrictive: combination of tense effusion in pericardial space and constricted by the thickened pericardium
- adhesive: non-constrictive
How do we often manage pericarditis?
- often self-limiting - triage and consider hospital admission
- NSAIDs can help alleviate symptoms - aspirin, ibuprofen, naproxen
- PPI prophylaxis to protect against effects of high doses of NSAIDs
- treat potential underlying cause - TB, immune processes, metabolic disorders, cardiac surgery
When do we consider hospital admission in pericarditis? (5)
Underlying aetiology OR high-risk features:
- high fever >38
- subacute course (Sx over several days without clear-cut acute onset)
- evidence of large pericardial effusion (diastolic echo-free space >20mm)
- cardiac tamponade
- failure to respond within 7d to NSAIDs
When do we do pericardiocentesis in pericarditis?
If you suspect cardiac tamponade
How do we manage idiopathic or viral pericarditis (non-purulent)?
- NSAID plus PPI
-
colchicine - adjuvant therapy which improves response to medical Rx and reduces rate of recurrence
- main side effect: diarrhoea
- do NOT give colchicine if TB
How do we manage purulent pericarditis?
- IV Abx (anti-Staphylococcus + aminoglycoside)
- specialist management
What is the surgical management for cardiac tamponade?
- pericardiocentesis - pericardial needle aspiration
- neoplastic disease: percutaneous balloon pericardiotomy
What is the surgical management for pericarditis in recurrent disease?
Pericardiectomy (complete removal of pericardium) - in cases of constrictive pericarditis, or TB that does not resolve
What are some complications of pericarditis? (3)
- pericardial effusion (urgent pericardiocentesis)
- cardiac tamponade (urgent pericardiocentesis)
- chronic constrictive pericarditis
What are poor prognostic signs of pericarditis? (5)
- high fever >38
- subacute course (over several days, no clear-cut acute onset)
- evidence of large pericardial effusion (diastolic echo-free space >20mm)
- cardiac tamponade
- failure to respond within 7 days to NSAIDs
