Pericardium

Question 1

What is the pericardium?

Answer 1

(1. ) Double layered sac containing the heart and great vessels.
(2. ) Visceral single cell layer adherent to epicardium
(3. ) Fibrous parietal layer (outermost layer) comprising of collagen and elastin fibres. Keeps heart in place
(4. ) Pericardial cavity between the two layers (serous pericardium) contains 50ml of serous fluid

Question 2

What is Acute Pericarditis? And its epidemiology?

Answer 2

(1. ) Pericarditis = inflamed pericardium
(2. ) Pericarditis can present with or without pericardial effusion (fluid to accumulate around the heart).

(3.) Epidemiology: (1) Seasonal with Viral trend, (2) Higher in younger healthy pts

Question 3

Diagnosis of acute pericarditis?

Answer 3

Clinical Diagnosis is made with 2 from:

• Chest Pain
• Friction Rub (severe): thickened layers rub against each other
• ECG changes
• Pericardial Effusion

Question 4

Aetiology of Acute Pericarditis? (9)

Answer 4

(1. ) Usually idiopathic
(2. ) Viral [common]
(3. ) Bacterial - staph, strep, TB
(4. ) Autoimmune
(5. ) Secondary metastatic tumours
(6. ) Uraemia pericarditis
(7. ) MI or Post-MI injury (Dressler’s Syndrome)
(8. ) Traumatic and Iatrogenic
(9. ) Medication

Question 5

Physical Examination + Hx of Acute Pericarditis +/- effusion

Answer 5

Hx = Cancer, rheumatological, pneumonia, cardiac procedure (PCI, ablation) MI?

Acute Pericarditis

(1. ) Pericardial Friction Rub at left sternal edge
(2. ) Sinus tachycardia
(3. ) Fever
(1. ) Sharp central chest pain may radiate to neck and/or shoulders.
- Worse = deep breathing, swallow, cough, lie down.
- Better = sitting up, lean forward.

Effusion

(4. ) Pulus paradoxus
(5. ) Beck’ triad: Hypotension, elevated JVP, quiet heart sound
(6. ) Other sx as a sign of low CO = SoB + Light headedness

Question 6

Investigation of Acute Pericarditis

Answer 6

1. ECG
   - Elevated J point (scoped elevated ST segment)
   - PR depression
2. Bloods: FBC, CRP, U&E, LFTs etc
   - High ESR suggest tumours, autoimmune
   - Troponin - Elevation suggest myopericarditis
3. CXR
   - May show pneumonia, malignancy, flask shaped heart (effusion present)
4. ECHO
   - Detect if any fluid has built up between the layers of pericardium

Question 7

Complications of Acute Pericarditis

Answer 7

(1. ) Pericardial effusion
- Small = usually asymptomatic. Large = TB, neoplasm.
- Large effusion will put pressure on heart preventing it from fully stretching out or relaxing between contractions.
- Prevents heart chambers from filling and pumping blood properly (cardiac tamponade).
- This decreases CO - making it a medical emergency

(2. ) Constrictive pericarditis
- Inflammation persisted for too long, immune cells initiate fibrosis of the pericardium.
- Pericardium thickens and contracts around the heart, making it hard for the ventricles to expand
- Over time, it becomes harder for heart to function - relax or expand, and SV dec and to compensate HR inc.

Question 8

Treatment and Management of Acute Pericarditis

Answer 8

(1. ) Admission required if poor prognosis is indicated
- Predicators of poor prognosis = Fever >38, subacute onset, large pericardial effusion, cardiac tamponade, lack of response to aspirin or NSAIDs after 1w

(2. ) Sedentary lifestyle i.e. rest until resolution of symptoms (applies to athletes)
(3. ) NSAIDs or Aspirin + Colchicine for 3m

(4. ) Surgical
- Pericardiocentesis - drains excess fluid if severe effusion
- Pericardiectomy - surgical removal of pericardium in constrictive pericarditis

Question 9

What is Cardiac Tamponade? What (3) causes it?

Answer 9

• Pericardial effusion that raises intrapericardial pressure, reducing ventricle filling and thus drops CO. This can lead to a rapid cardiac arrest.
• Tamponade may complicate any form of pericarditis
• Tamponade can be caused by: malignant disease, blood in pericardial space following trauma, or by rupture of myocardium following MI

Question 10

Clinical features of cardiac tamponade?

Answer 10

(1. ) Pulsus Paradoxus - due to drop in systolic pressure
(2. ) Raised JVP - Atria can’t expand enough to fit blood so goes back into veins
(3. ) Hypotension
(4. ) Dyspnoea
(5. ) Light headedness
(6. ) Tachycardia

Question 11

Investigations of Cardiac Tamponade

Answer 11

(1. ) ECG = Tachycardia, low QRS complex, electrical alteration (QRS complex has diff heights)
(2. ) Echocardiogram = shows excess fluid, ‘swinging’ heart
(3. ) Cardiac Catherization (measures pressure in chambers) = pressure is equal in all four chambers
(4. ) CXR

Question 12

Treatment of Cardiac Tamponade

Answer 12

• Medical emergency
• Pericardiocentesis
• Management of underlying conditions

Question 13

What is Chronic Pericardial effusion ?

Answer 13

• Chronic slow accumulation which allows for adaption of the parietal pericardium
• This compliance reduces the effect on diastolic filling of the chambers
• This rarely causes tamponade until the ‘limit of pericardial stretch’ is reached.
• This is often caused by ‘long term’ factors rather than a sudden trauma: Cancers, Uremic pericarditis, Hypothyroidism