Pericarditis (Complete*)

Question 1

What is acute pericarditis?

Answer 1

Inflammation of the pericardium

Question 2

Pericardial inflammation which spreads to the myocardium is known as?

Answer 2

Myopericarditis

Question 3

What is the most common cause of pericarditis?

Answer 3

Idiopathic (80-90% of cases)

Question 4

What are the main causes of pericarditis?

Answer 4

Infection

Malignancy

Cardiac:

Heart failure

Post-cardiac injury syndrome (e.g. MI)

Iatrogenic:

Radiation

Drugs and toxins

IBD drug therapy

Chronic conditions:

Rheumatological diseases

• RA
• Sarcoidosis
• SLE
• Vascultides (e.g. Bhecets)

Renal failure (Ureamic pericarditis)

Hypothyroidism (Pericardial effusion)

Ovarian hyperstimulation

Question 5

List examples of infectious causes of pericarditis

Answer 5

Viruses:
Coxsackie
HIV
Echovirus
CMV (Cytomegalovirus)
Herpesvirus

Bacterial
Staphylococcus
Pneumococcus
Streptococcus
Hameophilus
Mycobacterium tuberculosis

Fungi and parasites (Rare)

Question 6

What type of cancers most commonly cause pericarditis?

Answer 6

Lung cancer

Breast cancer

Hodgkin lymphoma

Question 7

List examples of drugs/toxins which can cause pericarditis

Answer 7

Phenytoin

• Anti-epileptic for tonic-clonic seizures

Doxorubicin

• Chemo for leukaemia

Hydralazine

Isoniazid

Methyldopa

Penicillins (Hypersensitivity)

Question 8

List examples of rheumatological diseases which can cause pericarditis

Answer 8

Rheumatoid arthritis

Sarcoidosis

SLE

Vasculitides (E.g. Bechet’s, Takayasu’s)

Question 9

What are the main clinical features of pericarditis?

Answer 9

Symptoms:

Fever

Pleuritic chest pain

• Worse when lying flat
• Better when leaning forwards

Prodromal coryzal symptoms (if viral cause)

Signs:

Pericardial friction rub

• High-pitched scratching noise
• Heard loudest over left sternal border during expiration

Pericardial effusion/cardiac tamponade

• Raised JVP
• Muffled heart sounds
• Hypotension

Question 10

What are the main characteristics of chest pain in pericarditis?

Answer 10

Pleuritic

Worse when lying flat

Better when leaning forward

Question 11

What are the features of pericardial friction rub

Answer 11

High pitched scratching noise

Heard loudest over left sternal border during expiration

Question 12

What investigations should be ordered in patients suspected of pericarditis?

Answer 12

Bedside:

ECG

• Widespread ST saddle-shaped elevation
• PR deppresion

Bloods:

FBC: Raised

ESR/CRP: Raised

Troponin

• Raised in 30% and indicates possible myopericarditis

Imaging:

Transthoracic echocardiogram

• Check for pericardial effusion

CXR

• Check for other causes of chest pain

Question 13

How does troponin elevation in pericarditis differ to MI?

Answer 13

Tends not to peak like MI and remains consistently elevated during the acute phase.

Question 14

What findings on ECG are suggestive of pericarditis?

Answer 14

Widespread ST elevation

Saddle-shaped ST elevation

PR deppresion: Most specific for pericarditis

Question 15

What investigation is diagnostic for pericarditis?

Answer 15

Transthoracic echocardiogram

Question 16

Which patients with pericarditis should be managed as an inpatient?

Answer 16

Either of following:

Fever > 38

Raised troponin

Question 17

What is the management plan for a patient with pericarditis?

Answer 17

TREAT UNDERLYING CAUSE

Conservative:
Exercise restriction: Until symptoms and inflammatory markers return to normal

Medicine:

First-line: NSAIDs (e.g. ibuprofen) +/- colchicine

Dressler syndrome or post MI:

First-line: High dose aspirin

Uraemic pericarditis:

First-line: Steroids

Surgical/invasive:

Pericardiocentesis: If purulent exudate or cardiac tamponade.

Pericardectomy: If adhesions or reccurent tamponade occurs

Question 18

Pericarditis is typically managed as outpatient. When would patients be treated as inpatient?

Answer 18

High risk features such as:

> 38 degrees fever

Elevated troponin (myopericarditis)

Large pericardial effusion or tamponade

Immunosuppression

Trauma

On oral anticoagulants

Subacute cause

Not responding to initial treatment (after 1-2 weeks)

Question 19

How is viral/idiopathic pericarditis managed?

Answer 19

NSAIDs + Colchicine

Question 20

Why is colchicine given in adjunct with NSAIDs?

Answer 20

Reduces risk of recurrence

N.B. Should be continued for 3 months

Question 21

Colchicine should be avoided in which groups of patients?

Answer 21

Renal impairement

Hepatic impairment

Question 22

How is bacterial pericarditis managed?

Answer 22

IV ABs

Pericardiocentesis if purulent exudate present

Question 23

Corticosteroids in 2nd line management of pericarditis should be avoid in which types of pericarditis and why?

Answer 23

Viral pericarditis

Due to risk of reactivation

Question 24

What are complications of pericarditis?

Answer 24

Pericardial effusion

Cardiac tamponade

Constrictive pericarditis (Chronic complication)

Question 25

What is constrictive pericarditis?

Answer 25

Scarring and loss of elasticity of the pericardial sac due to pericarditis. N.B. Results in HF due to reduced filling

Question 26

Constrictive pericarditis tends to develop due to which type of pericarditis?

Answer 26

TB pericarditis

Question 27

What are the main signs/symptoms of constrictive pericarditis?

Answer 27

**Kussmaul's sign** (Rise in JVP during inspiration) Early diastolic pericardial knock Signs of fluid overload Exertional dyspnoea Raised JVP Quiet heart sounds (If pericardial effusion present) Third heart sound (S3): Due to rapid early diastolic filling

Question 28

What are the key differences between cardiac tamponade and constrictive pericarditis

Answer 28

Question 29

What findings on CXR are indicative of constrictive pericarditis?

Answer 29

Pericardial calcification

Question 30

What ECG finding is most specific for pericarditis?

Answer 30

PR deppresion