1. Which arteries perfuse the pericardium? 2. Which nerve innervates the pericardium?

1. mammary arteries 2. phrenic nerve

Pericarditis - intrinsic Flashcards by S A

What is pericarditis?

inflammation of the pericardium

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Which arteries perfuse the pericardium?
Which nerve innervates the pericardium?

mammary arteries
phrenic nerve

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What are the 2 layers of the pericardium, their major characteristics and their function?

Inner visceral layer

microvillous surface
secretes pericardial fluid

Outer parietal layer

composed of collagen & elastin fibrils
provides structure to pericardium

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What is the function of the pericardium?

protects heart
restrains heart

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pWhat is the process causing all the signs and symptoms of pericarditis?

inflammation of the pericardial tissue

(well innervated, hence severe pain)

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What is the cause of concomitant pericardial effusion during pericarditis?

response to the inflammation of the pericardium

The normal pericardium is permeable to water and electrolytes and pericardial fluid is in dynamic equilibrium with the blood serum

Inflamed pericardial tissue impairs this equilibrium

Hence there is a collection of fluid (pericardial effusion)

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Why does inflamed pericardial tissue impair the dynamic equilibrium between the pericardium and blood serum?

Due to local production of inflammatory mediators e.g. cytokines, TNF, ILs

can cause weeping of fluid from the visceral pericardium,
AND exudation of larger molecules that attract additional fluid & impair resorption

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What are the more common causes of pericarditis?

90% of cases:

idiopathic
viral infections
autoimmune

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Name some viruses that can cause pericarditis

Coxsackie virus A9 or B1-4
Echo 8
mumps
EBV
cytomegalovirus
varicella
rubella
HIV
Parvo-19

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What are the less common causes of pericarditis?

10% of cases:

metabolic disorders
fungal/bacterial/parasitic
secondary immune processes
pericarditis and pericardial effusions in diseases of surrounding organs
trauma
neoplasms
certain drugs

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Name some autoimmune causes of pericarditis

rheumatoid arthritis
systemic sclerosis
reactive arthritis
familial Mediterranean fever
systemic vasculitides
IBD

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What are some secondary immune causes of pericarditis?

rheumatic fever
post-cardiotomy syndrome
post-MI syndrome

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Name some metabolic disorders that can cause pericarditis

uraemia
myxoedema

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Name some iatrogenic causes of pericarditis

radiotherapy
cardiac surgery
Percutaneous cardiac interventions

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How many days does it take for pericarditis to occur post-MI?

early: 1 to 3 days after an MI (pericarditis epistenocardica)

delayed: weeks/months after an MI (Dressler’s syndrome).

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What are the risk factors for pericarditis?

non-modifiable

male > female
age: 20-50yrs
transmural MI (for early pericarditis)
neoplasm
uremia
autoimmune disorders

iatrogenic

cardiac sugery
dialysis

is it viral or bacterial pericarditis that is purulent?

bacterial

Which types of neoplasm tend to affect the onset of pericarditis

local tumour invasion
lymphatic spread
haematogenous spread of a malignant neoplasm

rare = Primary malignant pericardial disease

Summarise the epidemiology of pericardiits

adults (typically between 20 to 50 years old)
men > women

What are the presenting symptoms of pericarditis?

chest pain
- substernal / left praecordial —> trapezius ridge (back)
- ‘sharp, stabbing’
- sudden onset
- worsened by lying down
- relieved by sitting up or bending forward
- no change on exertion
prodrome: myalgias & malaise

What are the signs of pericarditis O/E?

~fever

ausculation

pericardial rub - ‘squeaky’
~ faint heart sounds (due to pericardial effusion)
~ Cardiac Tamponade signs

Explain where and how to hear pericardial rub on ausculation

left sternal edge
pt leaning forward
end-expiration.

What are the signs of cardiac tamponade?

Beck’s Triad (signs associated with acute cardiac tamponade)
- Raised JVP
- Low Blood Pressure
- Muffled Heart Sounds
Tachycardia
Pulsus paradoxus

What is pulsus paraxodus?

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

What are the primary investigations for ?pericarditis

* **ECG** _bloods_ * **serum troponin** * ~ high, indicates myocardial involvement * **pericardial fluid/blood culture** * to exclude purulent pericarditis * Pericardial fluid: bacterial, fungal, tuberculous causes * bloods: culture. * **ESR** * **CRP** * **serum urea** * to determine if ureamic cause * **FBC** * Leukocytosis w left shift ~ purulent pericarditis/infectious cause _imaging_ * **CXR** * to determine if there is pericardial effusion * **echocardiography** * Indicated especially when cardiac tamponade is suspected. * Can ~ help differentiate from ACS

What would an ECG show for a case of pericarditis?

* 1st: **PR segment depression** * 2nd: **_widespread_** **upwardly concave (saddle-shaped) ST-segment elevation**

_What might a CXR show if:_ a) acute pericarditis, but no pericardial effusion b) both acute pericarditis & pericardial effusion

a) normal b) in large pericardial effusions (\>300ml) * increased cardiothoracic ratio * water-bottle-shaped enlarged cardiac silhouette

What is the management of purulent pericarditis?

* immediate (life threatening) * requires immediate confirmation of diagnosis * via urgent pericardiocentesis 1. aminoglycoside e.g. gentomycin + NSAID (4wks) + PPI 2. then once pathogen determined, more specific Abx + ALWAYS TREAT UNDERLYING CAUSE

How is response to therapy for pericarditis monitored?

serial ESR (bloods) * should gradually fall back to normal range

What is the management of acute pericarditis? (non-purulent)

NSAID + colchicine if chest pain hasn't resolved in 2wks, and is not due to infectious cause: * + corticosteroid + ALWAYS TREAT UNDERLYING CAUSE

When is pericardiocentesis indicated?

* haemodynamic compromise * purulent pericarditis, * a high suspicion of tumour * tamponade * symptomatic effusion _effusion is analysed for:_ * glucose * protein * lactate dehydrogenase

For which pericarditis pts is steroid Tx contraindicated?

when pericarditis is due to viral cause (reactivation of the virus)

What is the recommended follow up for pericarditis?

Echos every 6/12months to ensure constrictive pericarditis has not developed

What are some complications of pericarditis?

* pericardial effusion with(out) cardiac tamponade * chronic constrictive pericarditis

What is the prognosis of pericarditis?

Depends on underlying cause & severity major prognostic factors: * **Evidence of a large pericardial effusion** * (i.e., diastolic echo-free space \>20 mm) * **High fever** * (i.e., \>38°C [\>100.4°F]) * **Sub-acute course** * (i.e., symptoms over several days without a clear-cut acute onset) * **Failure to respond within 7 days to a NSAID** Acute idiopathic pericarditis is generally a self-limited disease Purulent pericarditis is uniformly fatal if untreated and has a mortality of 40% with treatment