Pericarditis

Question 1

What are the two layers of the Pericardium?

Answer 1

Parietal

Visceral - Inner serous membrane made of a single layer of mesothelial cells

Question 2

What is in the Pericardial space?

Answer 2

15-50ml of pericardial fluid (ultrafiltrate of plasma)

Question 3

What is the drainage of the Pericardial fluid?

Answer 3

Into the thoracic duct and right lymphatic duct into the right pleural space

Question 4

What are the symptoms of acute Pericarditis?

Answer 4

Chest pain
Pericardial friction rub
Serial ECG changes

Question 5

What is constrictive Pericarditis?

Answer 5

Exudate and adhesions encase the heart within a non expansile pericardium

Question 6

What are some of the causes of Pericarditis?

Answer 6

Viral - Coxsackie
Idiopathic
TB
Bacterial - purulent pericarditis, ABx for 4 weeks
MI
Dresslers syndrome (Secondary pericarditis due to injury to the heart or pericardium)
Neoplasm
Renal failure
Inflammatory - RA, SLE. Sarcoidosis

Question 7

What are the 5 features of Pericardial pain?

Answer 7

Sharp (Like pleurisy)
Worse on inspiration (Like pleurisy)
Central chest pain (Like angina)
Radiating to left shoulder (Like angina)
Eased sitting forward
*May also have dyspnoea or fever*

Question 8

What are the signs of Pericarditis?

Answer 8

Tachycardia
Tachypnoea
Fever
Pericardial friction rub (Auscultate with diaphragm over the left lower sternal edge)
RHF and Hypotension if constrictive pericarditis
Pericardial knock (Loud, high pitched S3)

Question 9

What investigations would you perform in a patient with Pericarditis?

Answer 9

Bloods - FVC, U&Es, LFTs, CRP, CK, Troponin
Virology screen
Blood cultures
Rheumatoid factor
ANA
Anti DNA Antibodies
Tuberculin testing
Sputum for acid fast bacilli
ECG
ECHO if effusion suspected

Question 10

What ECG changes would you see in a patient with Pericarditis?

Answer 10

Stage 1) Widespread Saddle shaped ST elevation except for aVR and V1 which is usually depressed
Stage 2) Several days later - ST returns to normal, T wave flattens
Stage 3) T wave inversion
Stage 4) Weeks to months after onset ECG returns to pre-pericarditis baseline
*T wave inversion may persist with chronic inflammation associated with TB, Uraemia or Neoplasms

Question 11

How can you treat Pericarditis?

Answer 11

Address and treat the underlying cause
High dose NSAIDs (Aspirin, Indometacin or Ibuprofen) NOT POST MI (NSAIDs associated with cardiac rupture)
Corticosteroids can be used when disease does not subside rapidly
May do Pericardial window (Fistula into the pleural cavity) or Pericardectomy

Question 12

What is Myocarditis?

Answer 12

Inflammation of the muscle wall of the heart