Pericarditis

Question 1

What is pericarditis?

Answer 1

Inflammation of the pericardium.

Question 2

What are the two types of pericarditis?

Answer 2

• Acute

- Constrictive

Question 3

Which type of pericarditis do cardiac tamponade and pericardial effusion usually accompany?

Answer 3

• Acute pericarditis

Question 4

What is the most common cause of acute pericarditis?

Answer 4

• Viral causes:
• Enteroviruses e.g. coxsackieviruses & echoviruses
  Adenoviruses

Question 5

What are some non-infectious causes of acute pericarditis?

Answer 5

Autoimmune (next commonest cause):
- Sjorgrens syndrome
- Rheumatoid arthritis
- SLE
Neoplastic; secondary metastatic tumours (common, above all is lung or breast cancer)
Dressler’s syndrome - post cardiac injury syndromes

Question 6

Briefly describe the pathophysiology of acute pericarditis?

Answer 6

• The Pericardium becomes acutely inflamed, with pericardial vascularisation and infiltration with polymorphonuclear leukocytes
• A fibrinous reaction frequently results in exudate and adhesions within the pericardial sac, and a serous or hemorrhagic effusion may develop

Question 7

What are the signs of acute pericarditis?

Answer 7

• Pericardial friction rub present on auscultation
• Tachycardia
• Tachypnea
• Fever and lymphocytosis (increase in lymphocytes) if due to virus or bacteria

Question 8

You would make a diagnosis of acute pericarditis if 2 of what 4 signs are present?

Answer 8

• Chest pain
• Friction rub
• ECG changes
• Pericardial effusion

Question 9

What investigation is diagnostic in acute pericarditis?

Answer 9

ECG

Question 10

What would you see on the ECG in pericarditis?

Answer 10

• Widespread concave-upwards - Saddle shaped ST Elevation
• Diffuse ST segment elevation - present in all leads (must exclude STEMI which would have ST segment elevation but will be limited to the infarcted area e.g. anterior or inferior)
• PR depression

Question 11

On the ECG how would you differentiate pericarditis and a STEMI?

Answer 11

In pericarditis the ST elevation is in all leads whereas in a STEMI the ST elevation is limited to the infarcted area.

Question 12

Apart from ECG differences how else would you be able to differentiate between a STEMI and pericarditis?

Answer 12

Pain in STEMI will radiate to the neck and jaw and will not be relieved when sitting forward.

Question 13

What would a CXR show in pericarditis?

Answer 13

• May demonstrate cardiomegaly in cases of effusion - if found then confirm with echocardiography
• Often normal in idiopathic
• Pneumonia is common with bacterial pericarditis

Question 14

If the ESR is raised in pericarditis what is the most likely cause of the inflammation?

Answer 14

An autoimmune disease

Question 15

What is the main management in pericarditis?

Answer 15

• Analgesia for the pain

- Colchicine for 3 months to reduce risk of recurrence - however is limited by nausea and diarrhoea

Question 16

What is constrictive pericarditis?

Answer 16

When certain causes of pericarditis like TB, bacterial infection and rheumatic heart disease result in the pericardium becoming thick and fibrous and calcified.

Question 17

When does constrictive pericarditis become symptomatic?

Answer 17

If the pericardium becomes so inelastic that it disrupts the diastolic filling of the ventricles and the cardiac output is therefore decreased.

Question 18

What is constrictive pericarditis very similar to in terms of its presentation?

Answer 18

Restrictive cardiomyopathy, here the prognosis is poor and patients usually die less than a year after diagnosis. Constrictive pericarditis however is treatable.

Question 19

What can happen in the later stages of constrictive pericarditis?

Answer 19

The sub-endocardial layers of myocardium may undergo fibrosis, atrophy and calcification

Question 20

How does constrictive pericarditis present?

Answer 20

• Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inspiration
• Pulsus paradoxus - systolic bp drops by >10mmHg during inspiration
• Diffuse heart sounds
• Hepatosplenomegaly
• Ascites
• Oedema
• Right heart failure signs
• Atrial dilatation

Question 21

What investigations would you do in constrictive pericarditis and what are you likely to see?

Answer 21

• CXR: Small heart with or without pericardial calcification
• ECG: Low-voltage QRS
• Echocardiography: Thickened, calcified pericardium and small ventricular cavities with normal wall thickness
• CT/MRI: Helps distinguish it from Restrictive Cardiomyopathy

Question 22

What is the management of constrictive pericarditis?

Answer 22

Surgical removal of the pericardium - very risky.

Question 23

What is pericardial effusion?

Answer 23

The accumulation of fluid in the pericardial sac. It commonly accompanies an episode of acute pericarditis

Question 24

What is cardiac tamponade?

Answer 24

A pericardial effusion that raises intrapericardial pressure reducing ventricular filling thus dropping cardiac output

Question 25

What are the signs of pericardial effusion?

Answer 25

- Soft & distant heart sounds - Apex beat obscured - Raised jugular venous pressure - Bronchial breathing at left base - Ewart’s sign - compressed left lower lobe

Question 26

What are the symptoms of pericardial effusion?

Answer 26

- Dyspnea - Chest pain - Nausea

Question 27

What are the signs of cardiac tamponade?

Answer 27

- High pulse but low blood pressure - High jugular venous pressure - Muffled 1st & 2nd heart sounds - Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inspiration - Pulsus paradoxus - an exaggeration in the normal variation in pulse pressure seen with inspiration, such that there is a drop in systolic blood pressure - Reduced cardiac output

Question 28

What would you see on the CXR and on the ECG and on the echocardiogram in both pericardial effusion and cardiac tamponade?

Answer 28

- Large globular heart on CXR - Low voltage ORS complexes on ECG - Echo-free zone surrounding heart on Echo

Question 29

What are the diagnostic features of cardiac tamponade on an echocariogram?

Answer 29

- Late diastolic collapse of Right Atrium (remember most of L atrium is outside pericardium) - Early diastolic collapse of right ventricle

Question 30

What is Becks triad in the diagnosis of cardiac tamponade?

Answer 30

1. Falling blood pressure 2. Rising jugular venous pressure 3. Muffled heart sounds

Question 31

What is the treatment of pleural effusion?

Answer 31

- Most pericardial effusions resolve spontaneously - Pericardial effusions may re-accumulate most often due to malignancy - this may require a pericardial fenestration (a window in the pericardium is created to allow the slow release of fluid into the surrounding tissues)

Question 32

What is the treatment of cardiac tamponade?

Answer 32

- Seek expert help! - Requires Urgent Drainage via a Pericardiocentesis which will drain the fluid to relieve the pressure on the heart - Send fluid for culture, Ziehl-Nielsen stain and for cytology