Pericarditis - intrinsic Flashcards
What is pericarditis?
inflammation of the pericardium
- Which arteries perfuse the pericardium?
- Which nerve innervates the pericardium?
- mammary arteries
- phrenic nerve
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
What is the function of the pericardium?
- protects heart
- restrains heart
pWhat is the process causing all the signs and symptoms of pericarditis?
inflammation of the pericardial tissue
(well innervated, hence severe pain)
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)
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
What are the more common causes of pericarditis?
90% of cases:
- idiopathic
- viral infections
- autoimmune
Name some viruses that can cause pericarditis
- Coxsackie virus A9 or B1-4
- Echo 8
- mumps
- EBV
- cytomegalovirus
- varicella
- rubella
- HIV
- Parvo-19
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
Name some autoimmune causes of pericarditis
- rheumatoid arthritis
- systemic sclerosis
- reactive arthritis
- familial Mediterranean fever
- systemic vasculitides
- IBD
What are some secondary immune causes of pericarditis?
- rheumatic fever
- post-cardiotomy syndrome
- post-MI syndrome
Name some metabolic disorders that can cause pericarditis
- uraemia
- myxoedema
Name some iatrogenic causes of pericarditis
- radiotherapy
- cardiac surgery
- Percutaneous cardiac interventions
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).
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
- aminoglycoside e.g. gentomycin + NSAID (4wks) + PPI
- 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
