Pericarditis Flashcards
Define pericarditis.
Inflammation of the pericardium
Acute pericarditis = new-onset inflammation lasting <4-6 weeks
Pericarditis is diagnosed when 2 of 4 clinical criteria are present. Name these.
- Chest pain relieved by sitting forwards
- Pericardial friction rub
- Widespread ST elevation and/or PR depression on ECG
- Pericardial effusion
How common is pericarditis?
More common in 20-50yrs and in men
May account for ~5% of chest pain presentations in A&E
What are the causes of pericarditis?
- Idiopathic or viral infection (e.g. Coxsackie A9 /B, mumps, EBV, cytomegalovirus, varicella, rubella, HIV, Parvo-19) make up 90% of cases
- Systemic autoimmune disorders e.g. SLE
- Connective tissue disease (e.g. sarcoidosis)
- Secondary immune processes e.g. Dressler syndrome (2-10weeks after MI)
- Malignancy
- Trauma
- Uraemia (‘fibrinous’ pericarditis)
- Drugs
- Hypothyroidism
- Tuberculosis
What is a characteristic ECG finding in pericarditis?
- Widespread “saddle shaped” ST elevation - aka J point* elevation - J point depression and PR elevation in leads aVR and V1
- Shallow T-wave inversion may also be seen when adjacent cardiac muscle is affected
- No ‘reciprocal’ ST segment depression like in MI
- PR segment depressions
BUT normal in 10% of patients.
What are the risk factors for pericarditis?
- Male (3:1)
- Age 20-50yrs
- Transmural MI -
- ‘early’ = pericarditis epistenocardica
- ‘delayed’ = Dressler’s syndrome
- Cardiac surgery - in up to 20% of cases 4 weeks after CABG
- Neoplasm
- Viral and bacterial infection e.g. UTRI
- Uraemia or on dialysis
- Systemic AI disorders e.g. RA and lupus
Rare:
- Pericardial injury
- Mediastinal injury
What are the main two macroscopic types of acute pericarditis?
Fibrinous (dry)
Effusive (with purulent, serous or haemorrhagic exudate)
What is the triad of pericarditis?
- chest pain
- pericardial friction rub
- serial ECG changes
What is a medium to late complication of acute pericarditis?
- constrictive pericarditis (which impairs normal diastolic filling) e.g. due to effusion
- heart failure
What are the signs and symptoms of pericarditis?
- Acute onset, sharp, central, pleuritic chest pain
- Relieved by sitting forward
- Fever/flu-like symptoms (if viral) - prodrome of myalgias
- Pericardial friction rub
- Tamponade (if pericardial effusion)
Other:
Symptoms and signs of right-sided heart failure → suspect constrictive pericarditis.
What investigations would you do for pericarditis?
- ECG - upwards concave ST-segment elevation globally with PR depressions
Bloods:
- FBC - raised WCC if infectious
- CRP
- Troponin - may be mildly elevated; shows myocardial involvement
- CK
- CRP/ESR
- Pericardial fluid/blood culture - purulent pericarditis is life threatening and required pericardiocentesis
Imaging:
- CXR- normal unless large pericardial effusion (>300mL) –> water-bottle-shaped enlarged cardiac silhouette
- ECHO - TOE may show pericardial effusion. Can be done outpatient.
Why is viral serology not a first line investigation for pericarditis?
Viral serology is usually requested, but would not take priority in this instance as it takes 2 weeks for the result and rarely changes management.
When do patients with pericarditis have to be admitted?
Admit if 1 of major risk factors:
- high fever >38
- sub-acute course (i.e. without clear-cut onset)
- pericardial effusion (>20mm space)
- cardiac tamponade
- failure to respond to NSAID within 7 days
Admit if minor risk factors:
- Myopericarditis
- Immunosuppression
- Trauma
- Oral anticoagulant therapy
How is acute pericarditis managed?
All types of pericarditis:
- NSAID + PPI - 1-2 weeks before tapering
- AND Colchicine for 3 months - prevents recurrence; unless the patient has TB
- Exercise restriction - until CRP normalised or 3 months
If bacterial:
- +/- Corticosteroids low-mod dose - only once CRP normalised, until symptoms resolved
Purulent only:
- Pericardiocentesis - needle is inserted subcostally in the midline aiming towards the left shoulder.
- Systemic antibiotics - vanc and cef
If severe/adhesions/recurrent then pericardectomy.
How is TB pericarditis managed?
4-6 weeks of antituberculous treatment
What are the complications of pericarditis?
- Pericardial effusion +/- cardiac tamponade - effusion compresses chambers
- Chronic constrictive pericarditis
What is the prognosis with pericarditis?
- Acute idiopathic pericarditis is generally a self-limited disease in 70-90% of patients
- Purulent pericarditis has mortality of 40%
- Effusions are common with neoplastic pericarditis
- 15-40% recurrence
What does bloody pericardial effusion indicate?
Bloody pericardial effusion is most commonly caused by malignant disease
What is shown? What does it suggest in the context of pericarditis?
- Cardiomegaly only
- No pulmonary vascular congestion indicates pericardial effusion rather that congestive failure.
How do you treat uncomplicated pericarditis in a healthy individual? What might you add later?
Acute, uncomplicated pericarditis in a young and otherwise fit individual, may be treated with initial bedrest and pain relief with NSAIDs. Many also add low-dose colchicine as there is evidence it reduces recurrent disease.
What is a common SE of colchicine?
Diarrhoea - often limits its use
What does a combination of rash, arthropathy and pericarditis suggest?
SLE
What are the signs of cardiac tamponade in pericarditis?
- Raised JVP
- Tachycardia
- HF
- Pulsus paradoxus
- Becks triad (distended neck veins, muffled HS, hypotension) late signs
Tx: senior help + urgent pericardiocentesis
What is the MOA of colchicine?
Acts on neutrophil tubulin disruption
