Pericarditis

Question 1

Define pericarditis.

Answer 1

Inflammation of the pericardium

Acute pericarditis = new-onset inflammation lasting <4-6 weeks

Question 2

Pericarditis is diagnosed when 2 of 4 clinical criteria are present. Name these.

Answer 2

1. Chest pain relieved by sitting forwards
2. Pericardial friction rub
3. Widespread ST elevation and/or PR depression on ECG
4. Pericardial effusion

Question 3

How common is pericarditis?

Answer 3

More common in 20-50yrs and in men

May account for ~5% of chest pain presentations in A&E

Question 4

What are the causes of pericarditis?

Answer 4

• Idiopathic or viral infection (e.g. Coxsackie A9 /B, mumps, EBV, cytomegalovirus, varicella, rubella, HIV, Parvo-19) make up 90% of cases
• Systemic autoimmune disorders e.g. SLE
• Connective tissue disease (e.g. sarcoidosis)
• Secondary immune processes e.g. Dressler syndrome (2-10weeks after MI)
• Malignancy
• Trauma
• Uraemia (‘fibrinous’ pericarditis)
• Drugs
• Hypothyroidism
• Tuberculosis

Question 5

What is a characteristic ECG finding in pericarditis?

Answer 5

1. Widespread “saddle shaped” ST elevation - aka J point* elevation - J point depression and PR elevation in leads aVR and V1
2. Shallow T-wave inversion may also be seen when adjacent cardiac muscle is affected
3. No ‘reciprocal’ ST segment depression like in MI
4. PR segment depressions

BUT normal in 10% of patients.

The J point is the the junction between the termination of the QRS and the beginning of the ST segment.

Question 6

What are the risk factors for pericarditis?

Answer 6

• Male (3:1)
• Age 20-50yrs
• Transmural MI -
  
  • ‘early’ = pericarditis epistenocardica
  • ‘delayed’ = Dressler’s syndrome
• Cardiac surgery - in up to 20% of cases 4 weeks after CABG
• Neoplasm
• Viral and bacterial infection e.g. UTRI
• Uraemia or on dialysis
• Systemic AI disorders e.g. RA and lupus

Rare:

• Pericardial injury
• Mediastinal injury

Question 7

What are the main two macroscopic types of acute pericarditis?

Answer 7

Fibrinous (dry)

Effusive (with purulent, serous or haemorrhagic exudate)

Question 8

What is the triad of pericarditis?

Answer 8

• chest pain
• pericardial friction rub
• serial ECG changes

Question 9

What is a medium to late complication of acute pericarditis?

Answer 9

• constrictive pericarditis (which impairs normal diastolic filling) e.g. due to effusion
• heart failure

Question 10

What are the signs and symptoms of pericarditis?

Answer 10

• Acute onset, sharp, central, pleuritic chest pain
• Relieved by sitting forward
• Fever/flu-like symptoms (if viral) - prodrome of myalgias
• Pericardial friction rub
• Tamponade (if pericardial effusion)

Other:

Symptoms and signs of right-sided heart failure → suspect constrictive pericarditis.

Question 11

What investigations would you do for pericarditis?

Answer 11

• ECG - upwards concave ST-segment elevation globally with PR depressions

Bloods:

• FBC - raised WCC if infectious
• CRP
• Troponin - may be mildly elevated; shows myocardial involvement
• CK
• CRP/ESR
• Pericardial fluid/blood culture - purulent pericarditis is life threatening and required pericardiocentesis

Imaging:

• CXR- normal unless large pericardial effusion (>300mL) –> water-bottle-shaped enlarged cardiac silhouette
• ECHO - TOE may show pericardial effusion. Can be done outpatient.

Question 12

Why is viral serology not a first line investigation for pericarditis?

Answer 12

Viral serology is usually requested, but would not take priority in this instance as it takes 2 weeks for the result and rarely changes management.

Question 13

When do patients with pericarditis have to be admitted?

Answer 13

Admit if 1 of major risk factors:

• high fever >38
• sub-acute course (i.e. without clear-cut onset)
• pericardial effusion (>20mm space)
• cardiac tamponade
• failure to respond to NSAID within 7 days

Admit if minor risk factors:

• Myopericarditis
• Immunosuppression
• Trauma
• Oral anticoagulant therapy

Question 14

How is acute pericarditis managed?

Answer 14

All types of pericarditis:

• NSAID + PPI - 1-2 weeks before tapering
• AND Colchicine for 3 months - prevents recurrence; unless the patient has TB
• Exercise restriction - until CRP normalised or 3 months

If bacterial:

• +/- Corticosteroids low-mod dose - only once CRP normalised, until symptoms resolved

Purulent only:

• Pericardiocentesis - needle is inserted subcostally in the midline aiming towards the left shoulder.
• Systemic antibiotics - vanc and cef

If severe/adhesions/recurrent then pericardectomy.

Question 15

How is TB pericarditis managed?

Answer 15

4-6 weeks of antituberculous treatment

Question 16

What are the complications of pericarditis?

Answer 16

• Pericardial effusion +/- cardiac tamponade - effusion compresses chambers
• Chronic constrictive pericarditis

Question 17

What is the prognosis with pericarditis?

Answer 17

• Acute idiopathic pericarditis is generally a self-limited disease in 70-90% of patients
• Purulent pericarditis has mortality of 40%
• Effusions are common with neoplastic pericarditis
• 15-40% recurrence

Question 18

What does bloody pericardial effusion indicate?

Answer 18

Bloody pericardial effusion is most commonly caused by malignant disease

Question 19

Answer 19

Question 20

Answer 20

Question 21

What is shown? What does it suggest in the context of pericarditis?

Answer 21

• Cardiomegaly only
• No pulmonary vascular congestion indicates pericardial effusion rather that congestive failure.

Question 22

How do you treat uncomplicated pericarditis in a healthy individual? What might you add later?

Answer 22

Acute, uncomplicated pericarditis in a young and otherwise fit individual, may be treated with initial bedrest and pain relief with NSAIDs. Many also add low-dose colchicine as there is evidence it reduces recurrent disease.

Question 23

What is a common SE of colchicine?

Answer 23

Diarrhoea - often limits its use

Question 24

What does a combination of rash, arthropathy and pericarditis suggest?

Answer 24

SLE

Question 25

What are the signs of cardiac tamponade in pericarditis?

Answer 25

* Raised JVP * Tachycardia * HF * Pulsus paradoxus * Becks triad (distended neck veins, muffled HS, hypotension) late signs Tx: senior help + urgent pericardiocentesis

Question 26

What is the MOA of colchicine?

Answer 26

Acts on neutrophil tubulin disruption