Pericardial Diseases

Question 1

What are the pericardial diseases?

Answer 1

Acute pericarditis
Pericardial effusion
Constrictive pericarditis
Cardiac tamponade

Question 2

What is acute pericarditis

Answer 2

Inflammation of the pericardium

Question 3

Causes of acute pericarditis

Answer 3

Idiopathic
Secondary to
- viruses e.g. coxsachie, EBV, CMV, adenovirus, HIV
- bacteria e.g. staphs, streps, mycoplasma, legionella
- fungi and parasites - usually in immunocompromised
- autoimmune, systemic autoimmune diseases e.g. SLE, RA, vasculitis, IBD, sarcoid, amyloid
- drugs e.g. hydralazine, penicillin, isoniazid, chemotherapy
- metabolic e.g. ureamia, hypothyroidism, anorexia
- other e.g. trauma, surgery, malignancy, radiotherapy, MI, chronic heart failure

Question 4

Clinical features of acute pericarditis

Answer 4

Central chest pain 
- worse on inspiration or lying flat
- relief on sitting forward
Pericardial friction rub
Evidence of pericardial effusion or tamponade
Fever

Question 5

Investigations required for ?acute pericarditis

Answer 5

ECG
- widespread, concave ST elevation
- PR depression
- may be normal or non-specific 
Bloods - FBC, U&Es, TFTs, ESR and cardiac enzymes
CXR - cardiomeagly may indicate pericardial effusion
Echo - if suspected effusion 
CT - may show localised inflammation

Question 6

Management of acute pericarditis

Answer 6

NSAIDs or aspirin with gastric protection for 1-2 weeks
Add colchicine for 3 months to reduce the risk of recurrence
Rest until symptoms resolve
Treat the cause
Steroids or immunosuppressive therapies if not improving, or autoimmune cause

Question 7

What is a pericardial effusion

Answer 7

Accumulation of fluid in the pericardial sac (normally 10-50mls)

Question 8

Causes of pericardial effusion

Answer 8

Pericarditis 
Myocardial rupture - haemopericardium; surgical, stab wound, post-MI
Aortic dissection 
Pericardium filling with pus 
Malignancy

Question 9

Clinical features of pericardial effusion

Answer 9

Dyspnoea
Chest pain
Signs of local structures being compressed
- hiccoughs, nausea and bronchial breathing at the left base (compressed lower left lobe)
Muffled heart sounds
Look for signs of cardiac tamponade

Question 10

Diagnosis of a pericardial effusion

Answer 10

CXR - enlarged, globular heart if effusion >300ml
ECG
- low voltage QRS complexes
- alternating QRS morphologies
Echo - echo-free zone surrounding the heart

Question 11

How is pericardial effusion treated

Answer 11

Treat the cause 
Pericardiocentesis 
- may be diagnostic (bacterial pericarditis) or therapeutic (cardiac tamponade)
- send pericardial fluid for culture 
- ZN stain/TB culture and cytology

Question 12

What is constrictive pericarditis

Answer 12

The heart is encased in a rigid pericardium

Question 13

Causes of constrictive pericarditis

Answer 13

Unknown
Elsewhere TB
After ANY pericarditis

Question 14

Clinical features of constrictive pericarditis

Answer 14

Mainly of right heart failure with increased JVP
Kussmaul's sign - JVP rising paradoxically with inspiration 
Soft, diffuse apex beat
Quiet heart sounds 
S3 present 
Diastolic pericardial knock
Hepatosplenomealy 
Ascites
Oedema

Question 15

Investigations in ?constrictive pericarditis

Answer 15

CXR - small heart +/- pericardial calcification
CT/MRI - helps distinguish from restrictive cardiomyopathy
Echo
Cardiac catheterisation

Question 16

Management of constrictive pericarditis

Answer 16

Surgical excision

Medical treatment to address the cause and symptoms

Question 17

What is cardiac tamponade

Answer 17

A pericardial effusion that raises intrapericardial pressure, reducing ventricular filling and thus dropping the cardiac output
- can rapidly lead to cardiac arrest

Question 18

Clinical features of cardiac tamponade

Answer 18

As pericardial effusion 
Tachycardia 
Hypotension 
Pulsus paradoxus 
Increased JVP
Kussmaul's sign
Muffled S1 and S2

Question 19

How is cardiac tamponade diagnosed

Answer 19

Beck’s triad
- falling BP
- rising JVP
- muffled heart sounds
ECG - low-voltage QRS +/- electrical alternans
Echo - diagnostic
- echo free zone (>2cm or 1cm if acute) around the heart +/- diastolic collapse of right atrium and right ventricle

Question 20

How is cardiac tamponade managed

Answer 20

Expert help
Urgent drainage - fluid sent for culture
- ZN stain/TB culture and cytology