Armando Hasudungan
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Percarditis

Pericarditis

Summary of Pericarditis Pericarditis is inflammation of the pericardium. It is important to rule out other cardiac differentials. Ultrasound is gold standard for diagnosis. Treatment may involve pericardiocentesis if there is significant pericardial effusion.

Video: Pericarditis Overview

 

Overview

Overview Pericarditis is the most common form of pericardial disease and a relatively common cause of chest pain. The etiology of pericarditis may be infectious (eg, viral and bacterial) or noninfectious (eg, systemic inflammatory diseases, cancer, and post-cardiac injury syndromes). Tuberculosis is a major cause of pericarditis in developing countries but accounts for less than 5% of cases in developed countries, where idiopathic, presumed viral causes are responsible for 80% to 90% of cases. The diagnosis is based on clinical criteria including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion.

Definition
Acute pericarditis: An inflammation of the pericardial sac surrounding the heart.
Pericardial friction rub: Harsh, high-pitched, scratchy sound, with variable intensity, usually best heard at the left sternal border by auscultation, due to pericarditis.
Pericardial Effusion: Fluid that fills the pericardial space, which may be due to infection, haemorrhage, or malignancy. A rapidly accumulating effusion may lead to cardiac compromise.
Cardiac Tamponade: Increased pressure within the pericardial space caused by an accumulating effusion, which compresses the heart and impedes diastolic filling.

Anatomy of the Pericardium

The pericardium is a membranous layer that covers the heart and helps protect it, fixes the heart in the mediastinum and lubricates the heart.

The pericardium has two layers:

  • Serous layer
  • Fibrous layer

The pericardium has two layers:

  • The serous pericardium has a parietal and visceral layer and forms a closed sac
    • The parietal layer lines the inner surface of the fibrous pericardium and is reflected onto the heart as the visceral layer, or epicardium
    • Between the parietal and visceral pericardium is the pericardial space which contains serous fluid, important in
  • The fibrous pericardium is the outermost layer, and it is firmly bound to the central tendon of the diaphragm.

Overview


Anatomy of the pericardium

Watch

 

Risk Factors

Risk Factors for pericarditis include

Remember Patients with systemic autoimmune disease can have multiorgan involvement, such as pericarditis, nephritis, pleuritis, arthritis, and skin disorders.

Signs and Symptoms

  • Fever and malaise
  • Sharp retrosternal or left-sided chest pain.
    • The pain is often eased by leaning forward and is worse in the supine position
  • “pericardial rub” -friction rub on auscultation, often transient –
  • Tachycardia
Signs and Symptoms

Signs and symptoms 

Remember Acute Pericarditis triad: chest pain, friction rub and ECG changes

Pericarditis causing pericardial effusion can show

  • Signs of right sided heart failure – ↑JVP, peripheral oedema
  • Paradoxical pulse (systolic blood pressure decreases by more than 10 mm Hg during inspiration)

Differential Diagnosis

Remember to differentiate pericarditis from other life-threatening causes of chest pain, including acute coronary syndrome, myocarditis or pulmonary thromboembolism

Investigations

Remember Prompt echocardiography may be required to determine the presence and amount of pericardial fluid.

Investigations

  • FBC
  • EUC
  • LFT
  • X-ray
  • Echocardiogram
  • Troponin and other cardiac markers
ECG

Acute pericarditis ECG show initial diffuse elevated ST segments ± depressed PR segment. The elevation in the ST segment is concave upwards. 2-5 d later ST isoelectric with T wave flattening and inversion.

PERICARDITIS VS MYOCARDIAL INFARCTION
ECG Acute pericarditis Acute MI
ST-segment elevation Diffuse in limb leads V2-V6 Depending on area of infarction (inferior, anterior or lateral)
PR-segment depression Present Absent
QRS complex changes Absent Loss of R-wave and development of Q-wave

Management

  • NSAIDs + PPIs help relieve symptoms
  • Colchicine and steroids are also used for as adjuncts and for more serious cases
  • For resistant recurrent pericarditis, seek specialist advice.
Management

Management 

In symptomatic pericardial effusion and cardiac tamponade cardiocentesis is performed.

Complications and Prognosis

Complications

High risk complications of pericarditis include pericardial effusion and chronic constrictive pericarditis. Significant inflammation of the pericardium can result in fluid build-up in the pericardial space; this can be blood if there is trauma to the capillaries. Pericardial effusion can be asymptomatic or symptomatic (signs of heart failure) and can lead to cardiac tamponade which requires immediate treatment (cardiocentesis)

Remember Constrictive pericarditis and pericardial effusion can mimic heart failure but both of these can themselves be differentiated
JVP

Jugular venous pressure Normally biphasic venous return to the heart (M shaped). In cardiac tamponade the total heart volume is fixed and so during ventricular diastole ( between “v-y” waves) the pressure of the JVP does not decrease -> “y” wave does not descend. In Constrictive pericarditis Friedreich’s sign there is prominant “y” wave descent

Constrictive Pericarditis Cardiac Tamponade Heart failure
Kusmaul’s sign Present Absent  Absent
Pulsus paradoxus Uncommon Present Absent
Jugular Venous Pressure (JVP) Increased Increased Increased
Percardial Knock (third heart sound, due to rapid ventricular filling’s being abruptly halted by the restricting pericardium) Present Absent Absent
Hypotension Variable Severe  Variable
Remember Kusmaul’s sign looks at JVP relationship with breathing. This is different to Kusmaul breathing which is air hunger, rapid deep breathing a sign of metabolic acidosis
Remember Constrictive pericarditis may show calcifications of the pericardium on chest x-ray or thickened pericardium on echocardiography. Definitive therapy is resection of the pericardium

Cardiac Tamponade

Classical Quatret of Tamponade: hypotension, increased JVP, tachycardia, pulsus paradoxus

Pathophysiology high intra-pericardial pressure → decreased venous return → decreased diastolic ventricular filling → decreased CO → hypotension and venous congestion

Investigation

  • ECG
  • Echocardiogram
  • Cardiac catheterization
cardiac tamponade

Pericardial effusion ECG showing alternating QRS complex axis. This fits into the clinical picture of cardiac tamponade

Managment

  • Pericardiocentesis – ultrasound guided
  • Pericardiotomy
  • Avoid diuretics and vasodilators (these decrease venous return to already under filled RV-> decrease LV preload -> decrease CO)
  • IV fluid may increase CO
  • Treat underlying cause

References

Best Practice
UpToDate
Toronto Essential Notes
Oxford handbook of Clinical Medicine