pericarditis

Question 1

describe the anatomy of the pericardium

Answer 1

• 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

Question 2

what attachments does the parietal layer have and what is this for?

Answer 2

fibrous attachments to fix the heart in the thorax

Question 3

what is acute pericarditis?

Answer 3

an inflammatory pericardial syndrome with or without effusion

Question 4

what is the clinical diagnosis of acute pericarditis made from?

Answer 4

with 2 of the 4:
1. chest pain
2. friction rub
3.ECG changes
4. pericardial effusion

Question 5

what are other clinical symptoms of acute pericarditis?

Answer 5

dyspnoea
cough
hiccups
systemic disturbance
PMH

Question 6

what are differential diagnosis for acute pericarditis?

Answer 6

Pneumonia
Pleurisy
Pulmonary Embolus
Chostocondritis
Gastro-oesophageal reflux
Myocardial ischaemia/infarction
Aortic dissection
Pneumothorax
Pancreatitis
Peritonitis
Herpes zoster (shingles)

Question 7

what investigations would take place for acute pericarditis?

Answer 7

Clinical examination
Pericardial rub – -pathognomonic, crunching snow
-Sinus tachycardia
-Fever
-Signs of effusion (pulsus paradoxus, Kussmauls sign)
ECG
Bloods
CXR
Echocardiogram

Question 8

what does pericarditis look like on an ECG?

Answer 8

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)

Question 9

describe the physiology of the pericardium

Answer 9

-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

Question 10

what is tamponade physiology?

Answer 10

Small amount of volume added to space has dramatic effects on filling, but so does removal of a small amount.

Question 11

describe chronic pericardial effusion

Answer 11

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

Question 12

what os the clinical diagnosis made with for pericarditis? ( aetiology)

Answer 12

2/3 from:
1. Chest pain
2. Friction rub
3. ECG changes
4. Pericardial effusion

Question 13

what are the infectious causes of pericarditis?

Answer 13

-Viral (common)
-Bacterial (some common)
-Fungal (very rare)
-Parasitic (very rare)

Question 14

what are the non infectious causes of pericarditis?

Answer 14

-Autoimmune e.g. rheumatoid arthritis
-Neoplastic e.g. tumours
-Metabolic

Question 15

describe the clinical presentation of pericarditis - chest pain

Answer 15

-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

Question 16

what are the other symptoms of pericarditis?

Answer 16

-Dyspnoea
-Cough
-Systemic disturbance – skin rash, joint pain
-Past medical history – cancer, pneumonia

Question 17

what are the signs of tamponade?

Answer 17

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

Question 18

what would an ECG with pericarditis look like?

Answer 18

-Diffuse ST segment elevation
-Concave ST segment – may resemble acute injury pattern of STEMI
-Saddle shaped

Question 19

what would blood tests look like with pericarditis?

Answer 19

FBC
ESR and CRP
Troponin
CXR

Question 20

what would blood tests look like with pericarditis?-Troponin

Answer 20

elevations suggest myopericarditis

Question 21

what would blood tests look like with pericarditis?- CXR

Answer 21

pneumonia common with bacterial, modest enlargement of cardiac silhouette rules out effusion

Question 22

what would blood tests look like with pericarditis?AFBC

Answer 22

modest increase in WCC, mild lymphocytosis
ESR and CRP

Question 23

how is pericarditis managed?

Answer 23

-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

Question 24

what would would major pericarditis look like?

Answer 24

-Fever >38˚C
-Large pericardial effusion
-Cardiac tamponade
-Lack of response to aspirin or NSAIDs after at least 1 week of therapy

Question 25

what would minor cardiac tamponade look like?

Answer 25

Myopericarditis
Immunosuppression
Trauma
Oral anticoagulant therapy

Question 26

what are the specific causes of pericarditis?

Answer 26

-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