Pericardial effusion & constrictive pericarditis

Question 1

What is pericardial effusion?

Answer 1

An accumulation of fluid in the pericardium.

It normally presents as asymptomatic or as pericarditis until it is very large.

Question 2

What are the clinical features of pericardial effusion?

Answer 2

Dyspnoea
Pleuritic chest pain
Raised JVP
Bronchial breathing at the left base (Ewart's sign, signifying a large effusion compressing the left lower lobe) 
Syncope, dizziness
Chest pain

Question 3

Diagnosis of pericardial effusion:

Answer 3

CXR, showing a large globular heart.
Echo - echo-free zone around the heart.
ECG - low voltage QRS complexes and electrical alternans.

Question 4

Management of pericardial effusion:

Answer 4

Treat the cause.
Pericardiocentesis - may be diagnostic if suspected bacterial pericarditis or therapeutic if cardiac tamponade.
Send fluids off for MC&S, ZN stain, TB culture and cytology.

Question 5

What causes pericardial effusion?

Answer 5

Anything that can cause pericarditis.

1. Idiopathic
2. Inflammatory conditions - SLE, RA
3. Viruses
4. Bacteria
5. Fungi
6. Haemopericardium - trauma or aortic dissection
7. Malignancy
8. Radiotherapy

Question 6

What is Ewart’s sign?

Answer 6

Bronchial breathing at the left base - suggests a large effusion that is compressing the left lower lobe.

Question 7

What is constrictive pericarditis?

Answer 7

Encasement of the heart within a rigid pericardium; it is often idiopathic in the UK but may be caused by TB or any other pericarditis.

Question 8

What are the clinic features of constrictive pericarditis?

Answer 8

Mainly of RIGHT-SIDED HEART FAILURE.
Raised JVP.
Kussmaul’s sign (where the JVP rises paradoxically with inspiration).
Soft, diffuse apex beat and quiet heart sounds.
S3.
Diastolic pericardial knock.
Hepatosplenomegaly, ascites and oedema.

Question 9

What is Kussmaul’s sign?

Answer 9

The JVP rises paradoxically with inspiration