Pericarditis

Question 1

What is acute pericarditis?

What causes it?

Answer 1

Inflammation of the pericardium

• Viral (Coxsackie B, echovirus, HIV)
• Post myocardial infarction
• Bacterial (pneumonia, rheumatic fever, TB)
• Other
  
  • Uraemia
  • Autoimmune rheumatic disease
  • Malignancy (breast, lung, leukaemia, lymphoma)
  • Trauma
  • Fungi

Question 2

What are the clinical features of pericarditis?

Answer 2

• Central chest pain worse on inspiration/ lying flat
  
  • +/- relief by sitting forward
  • +/- fever
• Pericardial friction rub
• Percardial effusion
• Cardiac tamponade

Question 3

What investigations can you do in pericarditis?

Answer 3

• ECG
  
  • Saddle-shaped ST segment
  • Normal/ non-specific
• Cardiac enzymes may be raised
• Viral serology/ blood cultures etc

Question 4

How would you treat pericarditis?

Answer 4

• Analgesia (eg Ibuprofen with meals)
  
  • No NSAIDs following MI as associated with myocardial rupture
• Treat cause
• Colchicine < Steroids/ Immunosuppressants

Question 5

What is pericardial effusion?

What are its causes?

Answer 5

Accumulation of fluid in the pericardial sac

Caused by any pericarditis (+Hypothyroidism)

Question 6

What are the clinical features of pericardial effusion?

Answer 6

• Dyspnoea
• Raised JVP (prominent X decent)
• Ewart’s sign; bronchial breathing at left base (large effusion compressing left lower lobe)
• Obscure apex & soft heart sounds
• Signs of cardiac temponade

Question 7

How would you diagnose pericardial effusion?

Answer 7

• Echocardiography (diagnostic)
  
  • Echo-free zone surrounding the heart
• Aspiration via pericardiocentesis (echo guided)
  
  • Sent for biochemical, microbiological & cytological investigations
• CXR
  
  • Large, globular heart
• ECG
  
  • Low-voltage QRS complexes
  • Alternating QRS morphologies (electrical alternans)

Question 8

How would you manage pericardial effusion?

Answer 8

• Treat the cause
• Pericardiocentesis
  
  • Can be echo guided
  • Pericardial fluid aspirated
  • Diagnostic if suspected bacterial pericarditis, or therapeutic in cardiac temponade
• Send pericardial fluid for culture, ZN stain/ TB culture & cytology

Question 9

What is constrictive pericarditis?

Answer 9

Heart encased in a rigid pericardium

Question 10

What can cause restrictive pericarditis?

Answer 10

• UK; **Idiopathic **& intrapericardial haemorrhage during cardiosurgery
• World; TB
• After any pericarditis

Question 11

What are clinical features of constrictive pericarditis?

Answer 11

• Right heart failure
  
  • ↑JVP (prominent X & Y descents)
  • Hepatosplenomegaly, ascites, oedema
• Quiet
  
  • Soft diffuse apex
  • Heart sounds + S3
• K
  
  • Kussmaul’s sign (JVP rising paradoxically with inspiration)
  • Knock - Diastolic pericardial

Question 12

What investigations would you do for constrictive pericarditis?

What would they show?

Answer 12

• CXR
  
  • Small heart +/- pericardial calcification
• Echo
  
  • Cardiac catheterization

Question 13

How would you treat constrictive pericarditis?

Answer 13

• Surgical excision

Question 14

What is cardiac tamponade?

Answer 14

Accumulation of pericardial fluid raises intra-pericardial pressure, hence poor ventricular filling and fall in cardiac output

Question 15

What can cause cardiac tamponade?

Answer 15

• Any pericarditis
• Drugs; hydralazine, isoniazid, minoxidil
• Trauma & surgery (cardiac catheterization, biopsy)
• Aortic dissection
• Pneumopericardiam
• Haemodialysis, Warfarin

Question 16

What are signs of cardiac tamponade?

Answer 16

Beck’s triad;

1. Decreased BP (impaired ventricular filling)
2. Distant heart sounds (fluid muffling S1 & S2)
3. Distended neck veins (inc JVP)

• Inc pulse
• Pulsus paradocus
• Kussmaul’s sign (JVP rising paradoxically with inspiration)

Question 17

How would you diagnose cardiac tamponade?

Answer 17

Beck’s triad, 3D’s;

• Distant heart sounds
• Distended jugular veins
• Decreased arterial pressure

Also;

• ECG; low voltage QRS +/- electrical alternans
• Echo; diagnostic, echo-free zone (>2cm, or >1cm if acute) around heart +/- diastolic collapse of right atrium & right ventricle

Question 18

How would you manage cardiac tamponade?

Answer 18

• Urgent drainage
• Send fluid for culture, ZN stain/ TB culture & cytology