Pericarditis

Question 1

Definitions

From IBCC

Answer 1

Acute- Symptoms for <1month
Chronic- Symptoms for>3months
Recurrent- Recurs after a symptom free period of >1month

Question 2

Epidemiology

Answer 2

M/C in younger Males
Recurrence common- occurs in about 30%

Question 3

Clinical presentation

Answer 3

• Pain
• Fever
• Dyspnoea
• Cough
• Hiccups

Question 4

Pain

Answer 4

• Onset- Sudden, often episodic, may last hours to days
• Location-Central, More localized than ischemic pain
• Character- stabbing/ piercing- sometimes dull( like AMI)
• Radiation-
  Classical: to the trapezius ridge (neck–shoulder region) OR,
  
  • Tip of shoulder (phrenic nerve/diaphragmatic irritation).
  • Down the left arm(like AMI)
• Intensity- severe
• Aggravating and relieving factors-
  Aggravated by- supine position, swallowing, deep breathing
  Relieved by- sitting up, leaning forward(reduces pericardial stretch)
• Associated factors-
  -Dysphagia(oesophageal compression)
  -Hiccups(phrenic nerve irritation)
  -Cough((pleural or pericardial irritation)
• Absent pain in subacute or chronic etiologies (less inflammatory):
  
  • Tuberculosis
  • Malignancy
  • Uremia
  • Post-radiotherapy

Question 5

Clinical findigs
Echo findings

ECG findings

Answer 5

=>Pericardial Friction Rub
->Diagnostic Value
* Sensitivity: ~30%
* Specificity: High (pathognomonic when present)
->Best Heard
* Left lower sternal border
* Patient leaning forward
* Heard best with diaphragm of the stethoscope.
* Often transient — may appear and disappear over hours.

⸻
=>Echocardiography:
Pericardial Effusion
->Sensitivity
* ~60% (moderate sensitivity).
* Presence supports, but absence does not exclude

Question 6

ECG Findings

Answer 6

key features of pericarditis

🔑 STE:
Concave or saddle-shaped.
STE is greatest in II and V5-V6.
STD in aVR.
No reciprocal STD (especially in aVL).
🔑 Upright, relatively small T-waves (in V6, STE is >25% height of the T-wave).
🔑 PR depression.
If large effusion–»low voltage complexes &/or Electrical alternans

Question 7

Other Labs

Answer 7

• Troponin- Mild elevation->higher may suggest myopericarditis
• CRP- Mild elevation
• Moderate leucocytosis

Question 8

Cardiac MRI

Answer 8

Indicated if:
* Definite pericarditis but concern for myocarditis
* Unclear diagnosis despite above invx
* Limited echo windows

Question 9

Indications for Pericardiocentesis

Answer 9

->Tamponade physiology
->Suspected bacterial/ tubercular aetiology
->Large pericardial effusion causing symptoms plus failure of anti inflammatory therapy

Question 10

Diagnosis of Pericarditis

Answer 10

2 out of 4 criterias to be satisfied:
* Chest pain consistent with pericarditis (~90% sensitive).
* ECG changes consistent with pericarditis, including isolated PR depression (~80% sensitive).
* Pericardial effusion on echocardiography that is new or worsening (~60% sensitive).
* Pericardial friction rub (~30% sensitive).

Question 11

Causes of Pericarditis

Answer 11

1). Infective
- Viral-Echo, Entero, HIV, Influenza
-Bacterial-TB,
-Fungal- rare
2). Inflammatory- RA, SLE, Scleroderma
3). Other autoimmune - Vasculitis
4). Metabolic- Uremia, Hypothyroidism
5). Traumatic
6). Post cardiac surgery-
* Early post-MI pericarditis (within days).
* Dressler’s syndrome (autoimmune reaction after MI, surgery, or trauma).
7). Malignancy - lung, breast, thyroid, Hematologic
8). Drug related- Chemotherapeutic agents,
Hypersensitivity pericarditis with amiodarone, clozapine
9). Radiation induced
10). Idiopathic

Question 12

Evaluation

Answer 12

Evaluation for the Etiology of Pericarditis

=>Focused History
Infective symptoms
Drug history
Comorbidities- Malignancy, autoimmune diseases, thyroid disorders,
H/O travel- risk of TB

=>Invx-
->Formal Echocardiography
Assess:
* Pericardial effusion (size, hemodynamic significance).
* LV/RV function: dysfunction suggests perimyocarditis.
* Associated valvular or structural abnormalities.

->Chest Radiograph
* Evaluate for:
* Pulmonary infection (pneumonia, pneumonitis).
* Tuberculosis.
* Cardiomegaly (if large effusion).

->Bloods-
CBE, Inflammatory markers- CRP, ESR
RFTs, TFTs
RF for RA, ANA for autoimmune diseases Vasculitis screen
TB screen if suspicion
HIV screen

Question 13

Treatment
General Principles

Answer 13

=>General Principles
* Most cases are idiopathic or viral, and respond to colchicine + high-dose NSAID/aspirin.
* Goal: relieve inflammation, prevent recurrence, and avoid constrictive evolution.
* Evaluate for underlying cause before steroid initiation.

Answer 14

=>I]First-Line Therapy (Idiopathic / Viral Pericarditis)

1. Aspirin or NSAID (Anti-inflammatory Backbone)

Rationale:
* Adequate anti-inflammatory dosing is essential; subtherapeutic dosing may relieve pain but fail to suppress inflammation → recurrence risk.
Aspirin- upto 1gm tds or
Ibuprofen- 600mg tds

2. PPI to prevent gastric ulceration

3). 2. Colchicine
->Mechanism: anti-inflammatory, inhibits leukocyte microtubule polymerization.
Benefits: reduces recurrence and treatment failure by ~50%.
Typical dosing:
* 0.5 mg twice daily (≥70 kg) or 0.5 mg once daily (<70 kg) for 3 months (first episode).
Notes:
* Use with caution in renal/hepatic impairment.
* Main side-effect: diarrhea (dose-dependent).

Answer 15

4). Adjunct Analgesia–>
Acetaminophen or short course of opioids

5). III. Corticosteroids
->Highly effective but risk of recurrence and steroid dependence → avoid unless indicated.

->Indications:
* Failure of NSAID + colchicine after adequate duration and dosing (with elevated CRP).
* Contraindication to NSAIDs/aspirin.
* Constrictive or effusive pericarditis on echo/CMR
* Pregnancy.

6). Anticoagulation Considerations
* Avoid if possible (risk factor for hemorrhagic effusion).
* No strong evidence that anticoagulation increases tamponade risk

7). Failure to improve or relapse → re-evaluate for non-idiopathic causes (TB, malignancy, autoimmune).

Question 16

Complications&
Factors determining Prognosis

Answer 16

->Complications

• Pericardial tamponade.
• Atrial fibrillation.
• Recurrent pericarditis.
• Constrictive pericarditis.

=>Predictors of complicated acute pericarditis
* Fever >38C.
* Subacute onset.
* Large pericardial effusion (>20 mm end-diastolic depth).
* Cardiac tamponade.
* Lack of response to aspirin/NSAIDs after at least one week of therapy.