Pericarditis

Question 1

Definition

Answer 1

· Inflammation of the pericardium

o It may be acute, subacute or chronic

Question 2

Epidemiology

Answer 2

· UNCOMMON

· < 1/100 hospital admissions

· More common in males

Question 3

Aetiology/Risk factors

Answer 3

· IDIOPATHIC

· Infective

· Connective tissue disease (e.g. sarcoidosis, SLE, scleroderma)

· Post-MI (within 24-72 hrs of MI - occurs in up to 20% of patients)

· Dressler’s Syndrome - pericarditis occurring weeks/months after acute MI

· Malignancy - lung, breast, lymphoma, leukaemia, melanoma

· Radiotherapy

· Thoracic surgery

· Drugs (e.g. hydralazine, isoniazid)

Question 4

Aetiology/Risk factors (infection causative organisms)

Answer 4

Most common causative organisms:

o Coxsackie B
o Echovirus
o Mumps
o Streptococci
o Fungi
o Staphylococci
o TB

Question 5

Presenting symptoms

Answer 5

· CHEST PAIN
o Sharp and central
o May radiate to the neck or shoulders
o Worse when coughing and deep inspiration (pleuritic pain)
o Relieved by sitting forward

· Dyspnoea

· Nausea

Question 6

Signs on physical examination (other)

Answer 6

· Fever

· Pericardial friction rub
o Heard best at lower left sternal edge, with patient leaning forward during expiration

· Heart sounds may be faint due to a pericardial effusion

Question 7

Signs on physical examination (cardiac tamponade)

Answer 7

· Cardiac Tamponade signs

o Beck’s Triad (signs associated with acute cardiac tamponade)
· Raised JVP
· Low Blood Pressure
· Muffled Heart Sounds

o Tachycardia

o Pulsus paradoxus
· Definition: an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration

Question 8

Signs on physical examination (constrictive pericarditis)

Answer 8

· Constrictive Pericarditis signs

o Kussmaul's sign
o Pulsus paradoxus
o Hepatomegaly
o Ascites
o Oedema
o Pericardial knock (due to rapid ventricular filling)
o AF

Question 9

Investigations (bloods)

Answer 9

o FBC
o U&Es
o ESR/CRP
o Cardiac Enzymes (usually normal)
o Other investigations for cause: blood cultures, ASO titres, ANA, rheumatoid factor

Question 10

Investigations (other)

Answer 10

· ECG - widespread saddle-shaped ST elevation

· Echocardiogram - assesses pericardial effusion and cardiac function

· CXR
o Usually normal
o May be globular if there is a pericardial effusion

Question 11

Management plan

Answer 11

· Acute - cardiac tamponade is treated with emergency pericardiocentesis

· Medical
o Treat underlying cause
o NSAIDs for pain and fever relief

· Recurrent
o Low-dose steroids
o Immunosuppressants
o Colchicine

· Surgical
o Pericardiectomy is performed in cases of constrictive pericarditis

Question 12

Possible complications

Answer 12

· Pericardial effusion

· Cardiac tamponade

· Cardiac arrhythmias

Question 13

Prognosis

Answer 13

· Depends on the underlying cause

· Viral cases have a GOOD prognosis

· Malignant pericarditis has a POOR prognosis