pericarditis Flashcards
describe the anatomy of the pericardium
- it has two layers that are continuous
- visceral single cell layer adherent to epicardium
- fibrous parietal layer 2mm thick
-acellular collagen and elastin fibres - 50 ml of serous fluid
what attachments does the parietal layer have and what is this for?
fibrous attachments to fix the heart in the thorax
what is acute pericarditis?
an inflammatory pericardial syndrome with or without effusion
what is the clinical diagnosis of acute pericarditis made from?
with 2 of the 4:
1. chest pain
2. friction rub
3.ECG changes
4. pericardial effusion
what are other clinical symptoms of acute pericarditis?
dyspnoea
cough
hiccups
systemic disturbance
PMH
what are differential diagnosis for acute pericarditis?
Pneumonia
Pleurisy
Pulmonary Embolus
Chostocondritis
Gastro-oesophageal reflux
Myocardial ischaemia/infarction
Aortic dissection
Pneumothorax
Pancreatitis
Peritonitis
Herpes zoster (shingles)
what investigations would take place for acute pericarditis?
Clinical examination
Pericardial rub – -pathognomonic, crunching snow
-Sinus tachycardia
-Fever
-Signs of effusion (pulsus paradoxus, Kussmauls sign)
ECG
Bloods
CXR
Echocardiogram
what does pericarditis look like on an ECG?
Diffuse ST segment elevation
Concave ST segment – may resemble acute injury pattern of STEMI
No reciprocal ST depression
Saddle shaped
PR depression
Mechanism is epicardial inflammation as adjacent to pericardium ( parietal is inert)
describe the physiology of the pericardium
-Mechanical function restrains the filling volume of the heart
-Similar properties to rubber - initially stretchy but becomes stiff at high tension
-Pericardial sac has a small reserve volume
what is tamponade physiology?
Small amount of volume added to space has dramatic effects on filling, but so does removal of a small amount.
describe chronic pericardial effusion
Chronic accumulation allows adaptation of the parietal pericardium
This compliance reduces the effect on diastolic filling of the chambers
As a result very slowly accumulating effusions rarely cause tamponade
what os the clinical diagnosis made with for pericarditis? ( aetiology)
2/3 from:
1. Chest pain
2. Friction rub
3. ECG changes
4. Pericardial effusion
what are the infectious causes of pericarditis?
-Viral (common)
-Bacterial (some common)
-Fungal (very rare)
-Parasitic (very rare)
what are the non infectious causes of pericarditis?
-Autoimmune e.g. rheumatoid arthritis
-Neoplastic e.g. tumours
-Metabolic
describe the clinical presentation of pericarditis - chest pain
-Severe, sharp and pleuritic (no crushing pain = pain)
-Rapid onset
-Radiates to arm more specifically trapezius ridge
-Relieved by sitting forward, exacerbated by lying down
what are the other symptoms of pericarditis?
-Dyspnoea
-Cough
-Systemic disturbance – skin rash, joint pain
-Past medical history – cancer, pneumonia
what are the signs of tamponade?
Pulsus paradoxus
-During inspiration reduce intra-thoracic and thus pericardial pressure
-Increased venous return to the RA and to the RV (suction)
-Increased RA compliance reduces LA filling and thus LV filling
-The space for the ventricles to expand is fixed due to the reduced compliance of the pericardium
-Fall in systolic blood pressure >10mmHg
what would an ECG with pericarditis look like?
-Diffuse ST segment elevation
-Concave ST segment – may resemble acute injury pattern of STEMI
-Saddle shaped
what would blood tests look like with pericarditis?
FBC
ESR and CRP
Troponin
CXR
what would blood tests look like with pericarditis?-Troponin
elevations suggest myopericarditis
what would blood tests look like with pericarditis?- CXR
pneumonia common with bacterial, modest enlargement of cardiac silhouette rules out effusion
what would blood tests look like with pericarditis?AFBC
modest increase in WCC, mild lymphocytosis
ESR and CRP
how is pericarditis managed?
-Sedentary activity until resolution of symptoms and ECG/CRP (probably only applies to athletes
-NSAID or aspirin
-Colchicine – limited by nausea and diarrhoea, reduces recurrence
what would would major pericarditis look like?
-Fever >38˚C
-Large pericardial effusion
-Cardiac tamponade
-Lack of response to aspirin or NSAIDs after at least 1 week of therapy
what would minor cardiac tamponade look like?
Myopericarditis
Immunosuppression
Trauma
Oral anticoagulant therapy
what are the specific causes of pericarditis?
-Viral pericarditis – most common cause in developed world
-Purulent bacterial pericarditis and effusion – rare and high mortality rate
-Tuberculous effusion TB pericarditis
-Dressler’s syndrome
