Pericarditis

Question 1

What is pericarditis?

Answer 1

Inflammation of the pericardium

Question 2

What is defined as acute pericarditis?

Answer 2

Pericardial inflammation lasting <4-6 Weeks

Question 3

How can you differentiate different types of pericarditis?

Answer 3

• Fibrinous (dry)/ constrictive
• Effusive –> pericardial effusion

Question 4

What is the epidemiology of pericarditis?

Answer 4

Large number undiagnosed, about 5% of Emergency chest pain presentation and 0.1% of Hospital admissions

More common in 20-50Y

More common in Men

Question 5

What are the causes for a pericarditis?

Answer 5

Majority ideopathic but might be due to

• infective (viral) pericarditis (together 90%)
• autoimmune underlying condition (e.g. Lupus, RA)
• 1-3 days after MI
• other, less common causes (traume, other conditions, bacterial/fungal infections etc.)

Question 6

What is the pericardium?

Answer 6

Layer of the hear that surrounds the myocardium and forms a sack around the heart

Question 7

What are the different layers of the pericardium?

Answer 7

Visceral pericardium (adherent to myocardium)

Parietal pericardium (outer layer

Question 8

What are risk factors for developing pericarditis?

Answer 8

Key risk factors include

• male sex,
• age 20 to 50 years,
• transmural MI,
• cardiac surgery,
• neoplasm,
• viral and bacterial infection,
• uraemia,
• dialysis treatment, and
• systemic autoimmune disorders.

Question 9

What are the presenting symptoms of pericarditis?

Answer 9

• chest pain (might be similar to MI)
  
  • sharp
  • stabbing
  • pleuritic
  • constant, not worse on exertion
• Trapezius ridge pain
  
  • the bottom portion of scapula on the back
• relief of pain when sitting up + leaning forwards

Question 10

What are signs of pericarditis on examination?

Answer 10

• Pericardial rub (<33% of cases)
  
  • high-pitched or squeaky. It is heard best at the left sternal edge with the patient leaning forward at end-expiration.
• • uncommon
    
    • fever
    • malaise
    • signs of right-sided heart failure

Question 11

What investigations would you do in a patient with suspected pericarditis?

Answer 11

1. ECG
2. Bloods
   
   • Culture/pericardial fluid culture
   • Serum troponin
   • ESR
   • CRP
   • Serum URA
   • FBC
3. Chest X-ray
4. Echocardiography

+ Consider

• Chest CT/Cardiac MRI
• Biopsy

Question 12

What would raised troponin levels in acute pericarditis indicate?

Answer 12

Myocardial involvement (in 35-50% of cases)

Question 13

Which ECG changes would you expect in someone with pericarditis?

Answer 13

• Global ST-elevation with PR depression
• (other way around in aVR and V1)

Question 14

Why do you do serum urea in a patient with actue pericarditis?

Answer 14

To determine cause

• Raised serum urea (>21.4 mmol/l) suggest uraemic cause

Question 15

What are possible differentials for a pericarditis?

Answer 15

• Ischaemia, MI –> shorter /more acute time frame and absence of pericardial rub
• PE
• Pneumonia
• Pneumothorax
• Costochondritis

Question 16

Develop a management plan for a patient with infective pericarditis

Answer 16

• Admit to Hospital if anything suggest underlying aetiology + risk factors for complications
• Determine cause

Management as outpatient

• Give NSAIDS as symptomatic management
• PPI for 4/52(Ibuprofen, after MI Aspirin)
• Exercise restriction
• If tamponade or symptomatic effusion:
  
  • consider pericardiocentesis
• Purulent
  
  • consider pericardectomy
• Non-purulent
  
  • colchicine
  • if idiopathic or viral: anti-viral therapy

Question 17

What are possible complications of pericarditis?

Answer 17

• Pericardial effusion
  
  • with clinical tamponade
• Purulent pericarditis
• Chronic constrictive pericarditis
  
  • treated by surgical pericardial resection

Question 18

How should a clinical temponade due to a pericardial effusion be managed?

Answer 18

If

• neoplastic pericarditis
• or purulent pericarditis suspected
  
  • see later
• large and symptomatic
  
  • Pericardiocentesis

Question 19

How would you treat a purulent pericardial effusion?

Answer 19

life-threatening

• Pericardiocentesis
  
  • with rinsing of pericardial cavaty
  • culture of fluid
• Blood cultures
• Systemic ABX
• NSAIDS
• oper surgical drainage

Question 20

How would you treat recurrent pericarditis?

Answer 20

NSAID plus colchicine, as well as exercise restriction

Question 21

What is the prognosis for patients with pericarditis?

Answer 21

Dependant on cause + other risk factors

• Ideopathic
  
  • normally self-limiting in 70-90% of cases
• purulent:
  
  • fatal without treatment, 40% mortality with treatment
• Other aetiologies also have different prognosis