PERICARDITIS AND PERICARDIAL EFFUSIONS Flashcards
What is the normal volume of fluid held within the healthy pericardium?
50 mL
What are the causes of acute pericarditis?
Infection
Acute MI
Uraemia
Autoimmune disease (SLE, rheumatic fever, RA, scleroderma)
Neoplastic disease
Other inflammatory disease (sarcoidosis, Whipple’s disease, Behcet’s syndrome)
What are the viruses commonly associated with acute viral pericarditis?
Coxsackie virus A and B
Echovirus
EBV
HIV
What are the bacteria commonly associated with acute bacterial pericarditis?
Pneumococci, staphylococcus, Gram-negative organims, Neisseria meningitidis, N. gonorrhoeae, Tuberculosis
What are the symptoms associated with acute pericarditis?
Sharp chest pain (central or left sided)
Pain alleviated sitting forwards
Aggravated by lying down or coughing
Dyspnoea - pain of deep inspiration
On examination, what signs might you find in a patient with acute pericarditis?
Fever
Tachycardia
Pericardial friction rub on ausculatation
Reduced heart sounds
Can you describe a pericardial friction rub?
High pitched scratching sound
Varies with time and may disappear
Sounds closer to the ear than a murmur
What investigations would you order for someone with suspected acute pericarditis?
Standard blood tests Autoantibody titres Cardiac enzyme and markers (troponin) Blood cultures ECG Chest x-ray Echo
What might blood tests show in someone with acute pericarditis?
Inflammatory picture Raised WCC Raised ESR Raised CRP Antinuclear autoantibodies Rheumatoid factor Cardiac enzymes Troponin T/I
If troponin T or I is elevated in a patient with acute pericarditis, what does this suggest?
That the inflammatory process involves the myocardium (myopericarditis)
What might the ECG of someone with acute pericarditis show?
Concave (saddle-shaped) ST elevation in all leads except AVR and V1
T-wave flattening or inversion a few days later
What might a chest x-ray of someone with acute pericarditis show?
Nothing in most uncomplicated cases
Pericardial effusion may be seen as enlargement of cardiac shadow
Pleural effusion
What is the best method of investigation to confirm a pericardial effusion?
Echo
What is the management of someone with uncomplicated viral or idiopathic acute pericarditis?
Bed rest and analegesia (NSAIDs)
Occasionally oral corticosteroids
What is the life threatening complication of acute pericarditis?
Cardiac tamponade
How is cardiac tamponade treated?
Oxygen
Bed rest - increase venous return
Pericardiocentesis - Drained with wide bore cannula inserted at the xiphisternum and directed towards the left shoulder under ECG monitoring. Once you see ECG changes, pull back slightly and leave to drain. Fluid should be sent for microscopy, culture and biochemical analysis of protein content.
What is Dressler’s syndrome?
Type III autoimmune reaction leading to a syndrome of fever, pericarditis and pleurisy occuring more than 1 week after a cardiac operation or myocardial infarction. Antibodies form against pericardial antigens.
How do patients with Dressler’s syndrome present?
Fever Malaise Chest pain Classic signs of pericarditis Arthritis
How is Dressler’s syndrome managed?
NSAIDs
Aspirin
Corticosteroids
What sign might you see on the skin of a patient with pericarditis caused by uraemia?
Ureamic frost
What is chronic constrictive pericarditis?
Thickening and fibrosis of the pericardium leading to restricts of filling of the heart.
What are the causes of chronic constrictive pericarditis?
Viral infection Tuberculosis Mediastinal radiotherapy Mediastinal malignancy Autoimmune disease
In chronic constrictive pericarditis, which side of the heart is affected most initially?
The right side
On examination, what signs might you find in someone with chronic constrictive pericarditis?
Raised JVP
Kussmaul’s sign - rise in JVP during inspiration
Rapid x and y descent of the JVP
Soft heart sounds
Irregularly irregular heart beat - AF is a common complication
How might you use the JVP to differentiate between chronic constrictive and cardiac tamponade?
There is no x and y descent of the JVP in cardiac tamponade
What investigations would you order for someone with suspected chronic constrictive pericarditis?
Blood tests Chest x-ray ECG Echo Cardiac catheterisation
What would the heart of a patient with chronic constrictive pericarditis look like on x-ray? What else might you see on the x-ray?
The heart size would actually be normal
There may be signs of a neoplasm or TB (seen as calcification)
Pleural effusions are not uncommon
What might you find on cardiac catheterisation of a patient with chronic constrictive pericarditis?
Raised left and right end-diastolic pressures
Normal left ventricular function on ventriculogram
How would you manage a patient with chronic constrictive pericarditis?
The only definitive treatment is pericardectomy
Antituberculous therapy if the underlying cause if found to be TB (continued for a year)
What is a pericardial effusion?
An accumulation of fluid in the pericardial space.
What are the causes of a pericardial effusion?
Acute pericarditis MI with ventricular wall rupture Chest trauma Cardiac surgery Aortic dissection Neoplasia
How much fluid must collect in the pericardial sac for the patient to feel symptoms of pericardial effusion?
The volume is not the important thing. It is the rate at which the fluid appears. 2L that comes on slowly can be accommodated for without an increase in intrapericardial pressure. However, as little as 100mL can cause tamponade if it appears suddenly.
What are the types of pericardial effusion?
Transudate
Exudate
Haemorrhagic
What defines something as a transudative pericardial effusion?
Less than 30g of protein/L
A fluid to serum protein ratio of less than 0.5
A fluid to serum lactate dehydrogenase ratio of less than 0.6
A fluid to serum glucose ratio of more than 1.0
What are some of the causes of a transudative pericardial effusion?
Congestive heart failure Hypoalbuminaemia Hypothyroidism Radiation Uraemia
What defines something as an exudative pericardial effusion?
More than 30g of protein/L
Fluid to serum protein ratio of more than 0.5
A fluid to serum lactate dehydrogenase ratio of more than 0.6
A fluid to serum glucose ratio of less than 1.0
What are some of the causes of an exudative pericardial effusion?
Infection Post MI Malignancy SLE Dressler's syndrome
What are some of the causes of a haemorrhagic pericardial effusion?
Uraemia Aortic dissection Ventricular wall rupture Trauma Postcardiac surgery
What are the symptoms associated with pericardial effusion with no cardiac tamponade?
Dull ache in the chest
Dysphagia
What are the symptoms of cardiac tamponade?
Dyspnoea
Abdominal swelling (due to ascites)
Peripheral oedema
On examination, what signs might you pick up in someone with a cardiac tamponade?
Low blood pressure Tachycardia Pulsus paradoxus Low volume pulse Soft heart sounds Low urine output Raised JVP
What investigations should be ordered for someone with suspected cardiac tamponade?
ECG
Chest x-ray
Echo
What would the ECG of someone with cardiac tamponade show?
Small voltage complexes with variable axis (electrical alternans - caused by movement of heart within fluid)
