Pericarditis, Cardiac Tamponade and Constrictive Pericarditis

Question 1

What are the causes of pericarditis, pericardial effusion and cardiac tamponade?

Answer 1

Pericarditis is an inflammation of the pericardium, the membranous sac which surrounds the heart. The pericardium is made of an outer fibrous layer (Parietal pericardium) and an inner serous membrane (Visceral pericardium). There is a small amount of fluid (plasma ultrafiltrate) in between the two layers.

Acute Pericarditis  Pericardial effusion (Extra fluid within the pericardial sac) Cardiac Tamponade (Extra fluid within the pericardial sac causes haemodynamic instability)

Chronic Pericarditis  Fibrosis of pericardium  Constrictive Pericarditis

Question 2

What are the causes of pericarditis?

Answer 2

Common – Idiopathic, Viral Infection (Coxsackie virus, Influenza, Adenovirus, EBV, HIV), Dressler’s Syndrome (2-5 weeks post MI), Uraemia

Others – Bacterial Infection (Strep, Staph, TB), Autoimmune (Sarcoidosis, Rheumatoid arthritis, SLE/Scleroderma), MI, Aortic Dissection, Hypothyroidism, Malignancy, Direct Trauma E.g. Stab wound

Question 3

What will you find on a history taking of pericarditis?

Answer 3

Symptoms:
Chest pain:
S – Precordial or retrosternal
Q -Sharp
I - Mild to severe
T - Constant
A -Lying Back or inspiration
R -Sitting up and Leaning Forward
Systemic - Fever, Chills, Lethargy, Cough
Rarely – Trouble breathings, palpitations
Symptoms of Pericardial effusion/Cardiac tamponade - light headedness, syncope, palpitations, cough, SOB

Risk Factors:
Commonly 20-50 years
Previous MI
Recent viral and bacterial infection
Renal Problems 
Any systemic autoimmune disorders 

Differentials:
Myocardial infarction - Typical central crushing chest pain that is not affected by position and risk factors. Global STR elevation rules out MI
Pleuritic pain – Worse on inspiration, not affected by position (PE, Pneumonia, lung Collapse). Ruled out with troponin
Peptic ulcer disease or oesophagitis – Affected by eating

Question 4

What will you find on examination of a patient with pericarditis, cardiac tamponade or constrictive pericarditis

Answer 4

Pericarditis –Pericardial Rub (heard best leaning forward), Tachypnoea, Tachycardia, Fever

Cardiac Tamponade – Becks Triad (Hypotension, Raised Systemic BP, Muffled Heart Sounds), Raised JVP, Pulsus Paradoxes (Fall >10mmHg in systolic BP on inspiration, may feel weaker pulse on inspiration). Ewart’s sign (Left Upper lobe of lung becomes dull to percussion with bronchial breathing as effusion causes collapse/consolidation)

Constrictive Pericarditis – Raised JVP, Kussmaul’s sign (JVP raises with inspiration), Hypotension

Question 5

What investigations will you order in pericarditis?

Answer 5

Bedside:
ECG - Saddle Shaped Global ST elevation and PR depression. Cardiac tamponade may cause electrical alternans (alternation of QRS complex amplitude or axis between beats)
Blood Cultures

Bloods:
FBC - To look for any infection
U&E – Looking for any renal failure that might predispose uraemia
ESR/CRP - Will be raised in due to inflammatory state
Troponin - May be raised slightly but can help to rule out MI
Creatine Kinase – Will be raised
Anti dsDNA and ANA (Lupus) and Rheumatoid factor (Rheumatoid arthritis)– If no obvious cause
Virology Screen
Sputum testing for acid fast bacilli – Ruling out TB

Imaging:
CXR – Rules out respiratory causes and may show pericardial effusion
Echo - If Suspected Pericardial effusion/Tamponade

Special Tests:
Pericardiocentesis if effusion suspected – Microscopy, Culture and Sensitivity

Question 6

What is the treatment of pericarditis or Pericardial effusion

Answer 6

Mild cases should be treated as an outpatient
Lifestyle:
Bed Rest
Stop anticoagulants if possible – Increases risk of tamponade

Medical:
1st Line - Naproxen
2nd Line - Corticosteroids (if not improving after 2 weeks)
Colchicine for 3 months to reduce risk of reinfection

Specific Treatments:
Bacterial Infection - Antibiotics
Autoimmune Condition (SLE, Scleroderma, RA) - Corticosteroids
Uraemia – Dialysis

Pericardial Effusion/Cardiac Tamponade:
Treat the underlying cause
Pericardiocentesis under US guidance with chest drain left in situ (in large or resistant effusions)