Pericarditis

Question 1

What purpose does the pericardium serve?

Answer 1

It helps to maintain compliance of the ventricles,increase cardiac efficiency by limiting dilatation, preserving starling curve, distributes hydrostatic forces, reduces external friction
AND protects against infection+malignant extension, reduces friction

Question 2

What is pericarditis?

Answer 2

Inflammation of the pericardium (fibrous reaction often leads to adhesions in the pericardium and then a serous reaction)

Question 3

A definite cause is found in what percentage of patients?

Answer 3

10-20%

Question 4

What is considered the likely cause if no cause is identified?

Answer 4

Viral

Question 5

What is the most common viral cause?

Answer 5

Coxsackie virus

Question 6

People who suffer a viral pericarditis often have had what recently?

Answer 6

A viral infection such as a sore throat in the past few weeks

Question 7

Name 9 other common causes of pericarditis…

Answer 7

Viral, TB, trauma (e.g. Post surgery), metastatic cancer, uraemia, MI (acute or delayed onset), rheumatic fever, SLE (most rheumatological conditions), rheumatic arthritis, bacteria

Question 8

What is the name given to the secondary form of pericarditis that has a delayed onset after having an MI

Answer 8

Dressler’s syndrome (occurs 2-3 weeks post MI and occurs in 7% of MIs, most recover in a few days and rarely leads to tamponade)

Question 9

What are the symptoms of pericarditis?

Answer 9

Usually sharp, retrosternal chest pain relieved by sitting up and leaning forward

Question 10

What aggravates pericarditis pain?

Answer 10

Worsened on inspiration (pleuritic), swallowing, coughing

Question 11

Where does pain radiate to?

Answer 11

Shoulder, trapezial ridge (esp. left) and precordium

Question 12

What are the signs of pericarditis on examination?

Answer 12

Pericardial rub on auscultation, dysponoea, orthopnoea, Beck’s triad if tamponade (hypotension, elevated systemic venous pressure often with jugular venous distention, and muffled heart sounds)

Question 13

How can you increase the loudness of pericardial rub?

Answer 13

Asking the patient to breathe in

Question 14

What feature if found is pathogenomic for pericarditis?

Answer 14

Pericardial rub

Question 15

What is the pericardium?

Answer 15

It is the two layers surrounding the heart, an outer fibrous sac and an inner serous membrane (epicardium) which are separated with 50ml of ultrafiltrate

Question 16

Why do chest XRs often not reveal much in the case pericarditis?

Answer 16

As many look normal until the cardio thoracic ratio is reduced in effusions of 300ml+

Question 17

What aetiologies should be checked before treatment?

Answer 17

TB and any other non idiopathic non viral causes however bar TB aetiology is not necessary for initiating treatment as most care is supportive

Question 18

What else should be identified when deciding management?

Answer 18

Does the patient have any high risk features such as tamponade or constriction that need to be dealt with urgently

Question 19

What are the major factors predicting a poor prognosis?

Answer 19

Fever (>38), subacute onset (symptoms slowly over several days), large effusion (diastolic echo free space over 20mm), tamponade, no response to NSAIDs/aspirin after a week

Question 20

What are the minor predictors of poor prognosis?

Answer 20

Myopericarditis, immunosupression, trauma, oral anti-coag therapy

Question 21

If patient has none of the poor prognostic factors, how should you manage them?

Answer 21

As outpatients, look for aetiology and trial with NSAIDs for a week, follow up or admit if not resolved

Also avoid too much physical activity

Question 22

How should you manage patients with any poor prognosis factors (major or minor)?

Answer 22

Admit, search for aetiology, treat any underlying cause, provide aspirin or NSAIDs, low dose colchicine to improve response to therapy, restrict physical activity

Question 23

What is incessant pericarditis?

Answer 23

Pericarditis that lasts 4-6 weeks without a clear cut remission after the episode (slowly resolves)

Question 24

How long can new onset pericarditis last up to and still be considered simply acute pericarditis?

Answer 24

Less than 4 weeks

Question 25

If pericarditis lasts 3 months or more what is it termed?

Answer 25

Chronic pericarditis

Question 26

Define recurrent pericarditis…

Answer 26

Another episode after a 4-6 week symptom free interval

Note: Treatment is much the same

Question 27

What is the recurrence rate and what reduces this?

Answer 27

15-30%

Colchicine reduces chance of recurrence

Question 28

What may appear on the ECG of someone with acute pericarditis?

Answer 28

Concave st elevation (saddle shaped)

Question 29

How would you treat tamponade?

Answer 29

Zheil neelson th testing and urgent drainage by expert