Pericarditis Flashcards

1
Q

summarise pericarditis?

A

sharp central chest pain, pleuritic, relieved by sitting forward, prodomal flu like symptoms, friction rub, may present as a tamponade ( raised JVP)

Pulse weaker on inspiration

no rise in CK or trops

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2
Q

define pericarditis?

A

inflammation of the pericardium

- may be acute, subacute or chronic

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3
Q

summarise the epidemiology of pericarditis?

A
  • UNCOMMON
  • < 1/100 hospital admissions

More common in males

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4
Q

what are the causes of pericarditis?

A

viruses- coxsackie, echovirus, EBV, CMV, adenovirus, mumps, varicella, HIV

Bacteria- TB- commonest worldwide, Lyme disease, Q fever, pneumonia, rheumatic fever, Staphs, streps, mycoplasma, legionella, MAI in HIV

Fungi and parasitic infection- v rare - usually in immunocompromised

Autoimmune- systemic autoimmune disease- e.g. SLE, RA, vasculitis e.g. Behcet, Takayasu, IBD, sarcoid, amyloid, Dressler’s

Drugs- e.g. procaine

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5
Q

recognise the presenting symptoms?

A
• CHEST PAIN
○ Sharp and central 
○ May radiate to the neck or shoulders 
○ Worse when coughing and deep inspiration (pleuritic pain)
○ Relieved by sitting forward
○ Worse when lying flat

• Dyspnoea

Malaise and myalgia may present in any cause of acute pericarditis especially in young adults

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6
Q

what is Beck’s triad?

A

signs associated with acute cardiac tamponade

raised JVP

Low blood pressure

muffled heart sounds

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7
Q

what are the signs of pericarditis on physical examination?

A
  • Fever
  • Pericardial friction rub on auscultation ->○ Heard best at lower left sternal edge, with patient leaning forward during expiration. Sounds like leather rubbing against each other

• Heart sounds may be faint due to a pericardial effusion

• Cardiac Tamponade signs (when fluid in the pericardium builds up resulting in compression of the heart)
○ Beck’s Triad (signs associated with acute cardiac tamponade)
▪ Raised JVP
▪ Low Blood Pressure
▪ Muffled Heart Sounds
○ Tachycardia
○ Pulsus paradoxus
Definition: an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration

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8
Q

what is meant by pulses paradoxus?

A

an abnormally large decrease in SBP ( >10mm Hg drop) and pulse wave amplitude during inspiration

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9
Q

what are the appropriate investigations for pericarditis?

A

ECG (MOST USEFUL - but remember normal in 10% of pts!) - widespread saddle-shaped (concave) ST elevation (without reciprocal ST depression), tachycardia, PR depression later followed by T wave flattening and inversion

Echocardiogram - assesses pericardial effusion and cardiac function (absence of LV wall motion abnormalities)

bloods

Chest Xray- may show pericardial effusion

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10
Q

describe the bloods in pericarditis?

A
  • FBC – WCC elevated if infectious cause
  • U&Es – urea elevated if uraemic cause
  • ESR/CRP - may be elevated (inflam)
  • Cardiac Enzymes (usually normal but may get mild elevation of trops) - remember to do at 12hrs again to defo exclude MI
  • Other investigations for cause: blood cultures (+ve if infectious cause), ASO titres, ANA, rheumatoid factor, viral serology
    SIDE NOTE: Blood cultures are extremely unlikely to be of any help at all in the diagnosis of acute pericarditis
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11
Q

outline a management plan for pericarditis?

A
  • Acute - cardiac tamponade is treated with emergency pericardiocentesis (aspiration of fluid from pericardial space)
  • Usually goes away itself but can suggest they take some ibuprofen

• Medical
○ Treat underlying cause if bacterial -> e.g. infectious => vancomycin + ceftriazone/gentamycin
○ NSAIDs/ Ibuprofen for pain and fever relief + aspirin +/- colchicine
○ May require PPIs to prevent gastric irritation from aspirin/NSAIDs – and monitor renal function

• Recurrent
○ NSAIDs + PPI + colchicine
○ Corticosteriods (2nd line) - prednisolone
○ Immunosuppressants (3rd line) - azathioprine
○ Colchicine – consider this before steroids and immunosuppressants

• Exercise is restricted until chest pain resolves and inflam markers have normalised

• Surgical
Pericardiectomy is performed in cases of constrictive pericarditis

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12
Q

what is a pericardial effusion?

A

accumulation of fluid in the pericardial sac ( normally 10-50mL)

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13
Q

what are the complications of pericarditis?

A
  • Pericardial effusion – pooling of fluid in pericardial space on CXR with no pulmonary congestion – do pericardiocentesis
  • Cardiac tamponade – a large pericardial effusion can put pressure on the heart- raises JVP
  • Cardiac arrhythmias
  • Heart Fail - Some forms of acute pericarditis can lead to a chronic constrictive pericarditis, which in turn can lead to heart failure because of chronic, limited ventricular filling, caused by the thickened and inflexible pericardium
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14
Q

outline the prognosis for patients with pericarditis?

A
  • Depends on the underlying cause
  • Viral cases have a GOOD prognosis
  • Malignant pericarditis has a POOR prognosis
  • 15-40% recur
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15
Q

what are the causes of a pericardial effusion?

A

pericarditis

myocardial rupture ( haemopericardium- surgical, stap wound, post MI)

Aortic dissection

pericardium filling with pus, malignancy

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16
Q

what are the clinical features of a pericardial effusion?

A

dyspnoea

chest pain

signs of local structures being compressed- hiccoughs ( phrenic nerve)

nausea ( diaphragm)

bronchial breathing at left base ( Ewart’s sign- compressed left lower lobe)

muffled heart sounds

look for signs of cardiac tamponade

17
Q

describe how to diagnose a pericardial effusion?

A

CXR shows an enlarged globular heart is effusion more thanan 300mL

ECG shows low voltage QRS complexes and may have alternating QRS morphologies ( electrical alternans )

Echo- shows an echo free zone surrounding the heart

18
Q

how do you treat a pericardial effusion?

A

treat cause

pericardiocentesis may be diagnostic ( suspected bacterial pericarditis)

or therapieteuc ( cardiac tamponade)

send pericardial fluid

send pericardial fluid for culture, Zn stain/ TB culture and cytology

19
Q

what is a cardiac tamponade?

A

pericardial effusion that raised intrapericardial pressure reducing ventricular filling and thus dropping cardiac output

=> can lead rapidly to cardiac arrest

20
Q

what are the signs of cardia tamponade?

A

increase pulse, decrease BP, pulses paradoxes, increased JVP, Kussmaul’s sign, muffled s1 and s2

21
Q

how do you diagnose cardiac tamponade?

A

Becks triad

  • falling BP
  • rising JVP
  • muffled heart sounds
  • ECG- low voltage QRS + electrical alternans

Echo= diagnostic-> echo free zone around heart +_diastolic collapse of right atrium and right ventricle