Pericarditis

Question 1

Define pericarditis

Answer 1

DEFINITION: inflammation of the pericardium

It may be acute, subacute or chronic

Question 2

Summarise the epidemiology of pericarditis

Answer 2

UNCOMMON

< 1/100 hospital admissions

More common in males

Question 3

Explain the aetiology/risk factors of pericarditis

Answer 3

1. IDIOPATHIC
2. Infective
   - Most common causative organisms:
   Coxsackie B
   Echovirus
   Mumps
   Viral more common than others;
   Streptococci
   Fungi
   Staphylococci
   TB - obviously worldwide, not UK
3. Connective tissue disease (e.g. sarcoidosis, SLE, scleroderma)
4. Post-MI (within 24-72 hrs of MI - occurs in up to 20% of patients)
5. Dressler’s Syndrome - pericarditis occurring weeks/months after acute MI
6. Malignancy - lung, breast, lymphoma, leukaemia, melanoma
7. Radiotherapy
8. Thoracic surgery
9. Drugs (e.g. hydralazine, isoniazid, penicillin, phenytoin)

Question 4

Recognise the presenting symptoms of pericarditis

Answer 4

• CHEST PAIN
○ Sharp and central
○ May radiate to the neck or shoulders
○ Worse when coughing and deep inspiration (pleuritic pain)
○ Relieved by sitting forward

• Dyspnoea
• Nausea

Question 5

Recognise the signs of pericarditis on physical examination

Answer 5

• Fever
• Pericardial friction rub
○ Heard best at lower left sternal edge, with patient leaning forward during expiration

• Heart sounds may be faint due to a pericardial effusion

• Cardiac Tamponade signs
○ Beck's Triad (signs associated with acute cardiac tamponade)
• Raised JVP
• Low Blood Pressure
• Muffled Heart Sounds
○ Tachycardia
○ Pulsus paradoxus
    - defined as an abnormally large decrease in SBP (> 10 mm Hg drop) and pulse wave amplitude during inspiration

-Also signs of constrictive pericarditis

Question 6

What are the signs of constrictive pericarditis?

Answer 6

Constrictive Pericarditis signs
○ Kussmaul's sign; JVP rise on inspiration
○ Pulsus paradoxus
○ Hepatomegaly 
○ Ascites
○ peripheral Oedema
○ 3rd HS - Pericardial knock (due to rapid ventricular filling)
○ AF - ecg

Question 7

Identify appropriate investigations for pericarditis

Answer 7

• ECG - widespread saddle-shaped ST elevation (+ pr depression)
• Echocardiogram - assesses pericardial effusion and cardiac function (gold?)

• Bloods
○ FBC
○ U&Es
○ ESR/CRP
○ Cardiac Enzymes (usually normal)
○ Other investigations for cause: blood cultures, ASO titres, ANA, rheumatoid factor

• CXR
○ Usually normal
○ Heart may be globular if there is a pericardial effusion

Pericardiocentesis is diagnostic and therapeutic

Question 8

Generate a management plan for pericarditis

Answer 8

• Acute - cardiac tamponade is treated with emergency pericardiocentesis/ pericardial tap

• Medical
○ Treat underlying cause
○ NSAIDs for pain and fever relief
- NSAID + colchicine + omeprazole (+ po prednisolone)

• Recurrent
○ Low-dose steroids
○ Immunosuppressants
○ Colchicine (anti-inflammatory)

• Surgical
○ Pericardiectomy is performed in cases of constrictive pericarditis

Question 9

Identify the possible complications of pericarditis

Answer 9

• Pericardial effusion
• Cardiac tamponade - build up of fluid in the pericardium
• Cardiac arrhythmias

Question 10

Summarise the prognosis for patients with pericarditis

Answer 10

• Depends on the underlying cause
• Viral cases have a GOOD prognosis
• Malignant pericarditis has a POOR prognosis

Question 11

A 54-year-old man is complaining of sharp, central chest pain that has arisen
over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He also has a low-grade fever. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis?

Answer 11

Dresslers syndrome; note the pericarditis 2-10 weeks post MI !!

Red flags!

Dressler’s should not be confused with a simple post-MI pericarditis which occurs within 2-4 days of an MI

Question 12

ECG findings with a pericardial effusion or tamponade?

Answer 12

ECG will show low voltages (less than 5 in LL and 10 in chest leads)
May show show electrical alternans . Because heart spins left to right inside the fluid.

Question 13

High risk features of pericarditis?

Impact on Mx?

Answer 13

What are high risk features in pericarditis? - fever, subacute onset, larg effusion or tamponade. In this case admit, give aspirin and colchicine.