Percarditis
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.
Aetiology and Risk Factors
Risk Factors
Patients with systemic autoimmune disease can have multiorgan involvement, such as pericarditis, nephritis, pleuritis, arthritis, and skin disorders.
Clinical Manifestations
- 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
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)
Diagnosis
Remember to differentiate pericarditis from other life-threatening causes of chest pain, including acute coronary syndrome, myocarditis or pulmonary thromboembolism.
- Myocardial Infarction (Acute Coronary Syndrome)
- Pulmonary Embolism
- Pneumonia
- Pneumothorax
- Costochondritis
Investigations
Prompt echocardiography may be required to determine the presence and amount of pericardial fluid.
- FBC
- EUC
- LFT
- X-ray
- Echocardiogram
- Troponin and other cardiac markers
| 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 |
Treatment
- 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.
In symptomatic pericardial effusion and cardiac tamponade cardiocentesis is performed.
Complications and Prognosis
Constrictive pericarditis and pericardial effusion can mimic heart failure but both of these can themselves be differentiated.
| 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 |
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.
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
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
Discussion