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. |
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:
The pericardium has two layers:
Anatomy of the pericardium
| Watch |
| Remember Patients with systemic autoimmune disease can have multiorgan involvement, such as pericarditis, nephritis, pleuritis, arthritis, and skin disorders. |
Signs and symptoms
| Remember Acute Pericarditis triad: chest pain, friction rub and ECG changes |
Pericarditis causing pericardial effusion can show
Remember to differentiate pericarditis from other life-threatening causes of chest pain, including acute coronary syndrome, myocarditis or pulmonary thromboembolism
| Remember Prompt echocardiography may be required to determine the presence and amount of pericardial fluid. |
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
In symptomatic pericardial effusion and cardiac tamponade cardiocentesis is performed.
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 |
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 |
| 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
Pericardial effusion ECG showing alternating QRS complex axis. This fits into the clinical picture of cardiac tamponade
Managment
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 |
