Pericarditis Flashcards
summarise pericarditis?
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
define pericarditis?
inflammation of the pericardium
- may be acute, subacute or chronic
summarise the epidemiology of pericarditis?
- UNCOMMON
- < 1/100 hospital admissions
More common in males
what are the causes of pericarditis?
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
recognise the presenting symptoms?
• 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
what is Beck’s triad?
signs associated with acute cardiac tamponade
raised JVP
Low blood pressure
muffled heart sounds
what are the signs of pericarditis on physical examination?
- 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
what is meant by pulses paradoxus?
an abnormally large decrease in SBP ( >10mm Hg drop) and pulse wave amplitude during inspiration
what are the appropriate investigations for pericarditis?
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
describe the bloods in pericarditis?
- 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
outline a management plan for pericarditis?
- 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
what is a pericardial effusion?
accumulation of fluid in the pericardial sac ( normally 10-50mL)
what are the complications of pericarditis?
- 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
outline the prognosis for patients with pericarditis?
- Depends on the underlying cause
- Viral cases have a GOOD prognosis
- Malignant pericarditis has a POOR prognosis
- 15-40% recur
what are the causes of a pericardial effusion?
pericarditis
myocardial rupture ( haemopericardium- surgical, stap wound, post MI)
Aortic dissection
pericardium filling with pus, malignancy
