4. Pericarditis

Question 1

How much serous fluid is there between the visceral and parietal pericardium?

Answer 1

50ml.

Question 2

What is the function of the serous fluid between the visceral and parietal pericardium?

Answer 2

It acts as a lubricant and so allows smooth movement of the heart inside the pericardium.

Question 3

What is the function of pericardium?

Answer 3

It restrains the filling volume of the heart.

Question 4

Why does chronic pericardial effusion rarely cause tamponade?

Answer 4

Chronic accumulation of effusions slowly -> parietal pericardium adapts.

Reduces the effect on diastolic filling of the heart chambers.

And so tamponade is prevented.

Question 5

What is acute pericarditis?

Answer 5

An inflammatory pericardial syndrome with or without effusion.

Question 6

How can acute pericarditis be clinically diagnosed?

Answer 6

Acute pericarditis can be clinically diagnosed if the patient has at least 2 of the following:

1. Chest pain.
2. Friction rub.
3. ECG changes.
4. Pericardial effusion.

Question 7

Describe the aetiology of pericarditis.

Answer 7

1. Viral (common) e.g. enteroviruses.
2. Bacterial e.g. mycobacterium tuberculosis.
3. Autoimmune e.g. RA, sjögren syndrome.
4. Neoplastic.
5. Metabolic e.g. uraemia.
6. Traumatic and iatrogenic.
7. 80-90% are idiopathic.

Question 8

List 3 viral causes of acute pericarditis.

Answer 8

Enteroviruses e.g. Coxsackie B
Herpesviruses e.g. EBV, HHV-6
Mumps
HIV
Adenoviruses
Parvovirus B19 (possible overlap with aetiologic viral agents of myocarditis)

Question 9

List 3 bacterial causes of acute pericarditis.

Answer 9

Pneumonia
Rheumatic fever
TB - Mycobacterium tuberculosis
Streps
Staphs

Question 10

List 5 causes, other than bacterial/viral infection, of acute pericarditis.

Answer 10

Fungi, MI, uraemia, rheumatoid arthritis, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy, sarcoidosis, idiopathic + drugs

Question 11

Give 5 symptoms of pericarditis.

Answer 11

1. Chest pain! Described as severe, sharp and pleuritic. Rapid onset. Pain can radiate to the arm.
2. Dyspnoea.
3. Cough.
4. Hiccups.
5. Skin rash.

Question 12

Describe the chest pain symptom of pericarditis.

Answer 12

• Severe, sharp and pleuritic
• Rapid onset.
• Left anterior chest
• Pain radiates to the arm, more specifically the trapezius ridge
• Relieved by sitting forward BUT exacerbated by lying down

Question 13

Why might someone with pericarditis have hiccups?

Answer 13

Because of irritation to the phrenic nerve.

Question 14

What investigations might you do on someone who you suspect to have pericarditis?

Answer 14

1. Clinical examination
2. ECG.
3. CXR.
4. Bloods.
5. Echocardiogram.

Question 15

What might be found in the blood tests for acute pericarditis?

Answer 15

1. FBC
   - Modest increase in WCC (white blood cell count)
2. ESR + CRP
   - High ESR
   - ANA (antinuclear antibodies) in young females -> SLE
3. Troponin
   - Elevations -> suggest myopercarditis
4. CXR
   - Often normal in idiopathic
   - Pneumonia common with bacterial causes

Question 16

What might the ECG look like in someone with acute pericarditis?

Answer 16

1. PR depression seen in most leads.
2. ‘Saddle shaped’ concave ST elevation.

Question 17

What might be observed/found upon clinical examination for acute pericarditis?

Answer 17

• Pericardial rub
• Sinus tachycardia
• Fever
• Signs of effusion (pulsus paradoxus, Kussmaul’s sign)

Question 18

What might be heard on auscultation of a patient with pericarditis?

Answer 18

Pericardial friction rub

Question 19

What is the major differential diagnosis of acute pericarditis?

Answer 19

MI - it is important to rule this out ASAP!

Question 20

What is the treatment for pericarditis?

Answer 20

1. Patients are advised to avoid strenuous activity until symptom resolution - sedentary activity advised - until symptoms die down and ECG/CRP
2. NSAID (e.g. ibuprofen) or aspirin -> high doses.
3. Colchicine (anti-inflammatory)

Question 21

What is constrictive pericarditis?

Answer 21

Heart is encased in a rigid fibrotic pericardium - prevents diastolic filling of ventricles.

Question 22

What causes constrictive pericarditis?

Answer 22

Most common in UK = idiopathic.
Globally = TB.
Also occurs after any pericarditis.

Question 23

What are the clinical features of constrictive pericarditis?

Answer 23

Those of right-sided heart failure - raised JVP, oedema, hepatomegaly, ascites, pulsus paradoxus, diffuse apex beat

Question 24

What 2 investigations would you carry out in constrictive pericarditis and what would you find?

Answer 24

1. CXR - normal/small heart + pericardial calcification.
2. CT/MRI - pericardial thickening/calcification

Question 25

How would you treat constrictive pericarditis?

Answer 25

Surgical excision of pericardium

Question 26

What is Dressler’s syndrome?

Answer 26

Myocardial injury stimulates formation of autoantibodies against the heart. Cardiac tamponade may occur. Dressler’s is a secondary form of pericarditis.

Question 27

What coronary event might Dressler’s syndrome develop after?

Answer 27

Can develop 2-10 weeks after an MI.