Pericarditis

Question 1

What are the 2 types of pericarditis?

Answer 1

Acute= inflammation of pericardium

Constrictive= stiffening of pericardium

Question 2

What is the structure of the pericardium?

Answer 2

Outermost layer of the cardiac wall consisting of 2 layers:

• parietal= outermost
• viscerial pericardium

Layers are seperated by pericardial cavity= filled with pericardial fluid

Question 3

What are the most common causes of pericarditis?

Answer 3

Top 3= viral/bacterial/TB

Viral= Coxsackie A and B virus/echovirus/adenovirus/mumps/hepatitis/varicella/zoster virus/HIV
(MOST COMMON)

Bacterial= TB/Staph aureus/streptococci/pneumococci/legionella
(Associated with purulent fluid in pericardial cavity

AI= SLE/RA/vasculitis/sarcoidosis/IBD/amyloidosis

Metabolic= uraemia/hypothyroidism

Vascular= post MI syndrome/ chronic HF

Trauma/surgery

Malignancy

Drugs= procainamide/hydrazaline/penicillin/isoniazid/chemo

Question 4

What are the symptoms associated with pericarditis?

Answer 4

Substernal chest pain

Can radiate to trapezius/neck/shoulders

Relieved by sitting forward and exacerbating by lying back and inspiration (think about inflammation of pericardium rubbing)

Viral prodrome

Sudden fever (Bacterial)

Gradual onset of fever, weight loss and night sweats (TB)

Question 5

What are the signs of pericarditis and what causes these signs?

Answer 5

Pericardial rub = early on
-due to inflamed layers rubbing together

Pulsos paradoxus= fall in systolic BP by >10mmHg during inspiration
-due to cardiac tamponade or constriction associated with pericarditis

Jugular venous distention

• stiffening/harden of pericardium leads to decreased filling
• means increased BV remains in systemic veins=> distention

Question 6

Why does a pericardial rub disappear later in pericarditis?

Answer 6

The accumulation of fluid between the parietal and visceral layers leads to them no longer rubbing against each other

Question 7

What are the acute diagnostic criteria for pericarditis?

Answer 7

Substernal chest pain

Pericardial rub

Wide spread ST elevation or PR depression

Question 8

What investigations would you do if you suspected pericarditis?

Answer 8

Serial ECG= ST elevation and PR depression
-get widespread “saddle shaped” ST elevation

FBC= WCC

CRP

U+E= uraemia

Troponin-> raised in 30% of cases
-need to be done at 12 hrs to exclude MI

Pericardial fluid microbiology = serology for viral cause
-NOT part of the initial tests because it takes 2 week for the results to come back and rarely changes manangement

Echo= effusion or tamponade

CXR= cardiomegaly might be suggestive of
pericardial effusion

Cardiac magnetic resonance (CMR)= can show localised inflammation

Question 9

How would you manage some one with viral pericarditis?

Answer 9

Symptom relief due to it usually being self-limiting

Eg analgesia/NSAIDs

Question 10

How would you manage someone with bacterial pericarditis?

Answer 10

Medical emergency

• antibiotics
• emergency drainage-
• IMPORTANT= send sample to microbiology so can get specific Abx

Question 11

How would you manage someone with TB pericarditis? When is a pericardiectomy indicated?

Answer 11

4-drug antituberculous regime
(RIPE)

Prednisolone= prevents constriction

Indicated when calcific form of TB pericarditis manifests
-can occur after treatment due to calcium deposition leading to stiffening

Question 12

Is pericarditis associated with arrythmias? Why?

Answer 12

NO

Pericardium is electrically inert

Question 13

What complications can occur due to pericarditis?

Answer 13

Cardiomegaly

Pericardial effusion
-can cause pericaridal tamponafe which leads to JVP elevation

Question 14

How would pericardial effusion present on CXR?

Answer 14

Enlarged heart but there will be absence of pulmonary vascular congestion (which might suggest CCF)

Question 15

Where is needle inserted in pericardiocentesis?

Answer 15

Subcostally in midline towards the left shoulder