pericarditis

Question 1

definition

Answer 1

Pericarditis is an inflammation of the pericardium. The acute form is defined as new-onset inflammation lasting <4-6 weeks. It can be either fibrinous (dry) or effusive with a purulent, serous, or haemorrhagic exudate. It is characterised clinically by a triad of chest pain, pericardial friction rub, and serial electrocardiographic changes. Constrictive pericarditis impedes normal diastolic filling and can be a medium to late complication of acute pericarditis. Pericarditis is the most common disease of the pericardium encountered in clinical practice.

Question 2

aetiology

Answer 2

• Idiopathic;
• infective (commonly, coxsackie B, echovirus, mumps virus, streptococci, fungi, staphylococci, TB);
• connective tissue disease (e.g. sarcoid, SLE, scleroderma);
• post-myocardial infarction (24–72 h) in up to 20% of patients;
• Dressler’s syndrome (weeks to months after acute MI);
• malignancy (lung, breast, lymphoma, leukaemia, melanoma);
• metabolic (myxoedema, uraemia);
• radiotherapy;
• thoracic surgery;
• drugs (e.g. hydralazine, isoniazid).

!! 90% are idiopathic or viral

Question 3

symptoms

Answer 3

Chest pain: Sharp and central, which may radiate to neck or shoulders. Aggravated by coughing, deep inspiration and lying flat. Relieved by sitting forward.
Dyspnoea, nausea.

Question 4

examination/signs

Answer 4

Fever, pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration), heart sounds may be faint in the presence of an effusion.

Cardiac tamponade: raised JVP, low BP and muffled heart sounds (Beck’s triad). Tachycardia, pulsus paradoxus (reduced systolic BP by >10 mmHg on inspiration).

Constrictive pericarditis (chronic): raised JVP with inspiration (Kussmaul’s sign), pulsus paradoxus, hepatomegaly, ascites, oedema, pericardial knock (rapid ventricular filling), AF.

Question 5

investigations

Answer 5

ECG: Widespread ST elevation that is saddle-shaped.

Echocardiogram: For assessment of pericardial effusion and cardiac function

Blood: FBC, U&E, ESR, CRP, cardiac enzymes (usually normal). Where appropriate: blood
cultures, ASO titres, ANA, rheumatoid factor, TFT, Mantoux test, viral serology.

CXR: Usually normal (globular heart shadow if >250 mL effusion). Pericardial calcification can be seen in constrictive pericarditis (best seen on lateral CXR or CT).

1st investigations:

• serial troponin (to make sure it’s not an MI)
• ECG
• pericardial fluid/blood culture
• ESR/CRP
• serum urea (to check if it’s a uraemic cause)
• FBC
• CXR
• echo

Question 6

treatment

Answer 6

Acute: Cardiac tamponade treated by emergency pericardiocentesis.

Medical: Treat the underlying cause, NSAIDs for relief of pain and fever.

Recurrent: Low-dose steroids, immunosuppressants or colchicine.

Surgical: Surgical excision of the pericardium (pericardiectomy) in constrictive pericarditis.

Question 7

complications

Answer 7

Pericardial effusion, cardiac tamponade, cardiac arrythmias.

Question 8

prognosis

Answer 8

Depends on underlying cause. Good prognosis in viral cases (recovery within about 2 weeks), poor in malignant pericarditis. Pericarditis may be recurrent (particularly in those caused by thoracic surgery).