Pericardial disease

Question 1

Describe the anatomy of the pericardium

Answer 1

The pericardium is a protective covering for the heart that confines its position in the mediastinum.

Visceral: inner serious membrane made of a single layer of mesothelial cells.
Parietal: outer membranes lines the fibrous sac.

Pericardial fluid (normal 20-49ml) drains via the thoracic duct and right lymphatic duct into the right pleural space.

Question 2

List the presentations of pericardial disease

Answer 2

Acute and relapsing pericarditis
Pericardial effusion and cardiac tamponade
Constrictive pericarditis

Question 3

Describe the symptomsof acute pericarditis

Answer 3

Pericardial pain:
Like pleurisy: Sharp, worse on inspiration
Like angina: Central chest pain, radiating to shoulder
Specific: Relieved by sitting forward

Viral/bacterial, rheumatic fever or MI:
-Usually fever, leucocytosis or lymphcytosis

Pericardial effusion/tamponade: Dyspnoea

Question 4

List 5 causes of acute pericarditis

Answer 4

Majority are idiopathic

Viral*: esp Coxsackievirus, painful but shortlived
Bacterial: Staph aureus is a frequent cause of purulent pericarditis in HIV patients, pneumonia
Tuberculosis: acute pericarditis + chronic low-grade fever, dyspnoea, night sweats, weight loss

Post-MI pericarditis: 20% of MI in first few days
Dressler syndrome: autoimmune response at 2-10wk

Malignant pericarditis: Mesothelioma, Carcinoma of bronchus/breast, Hodgkin’s lymphoma

Uraemic pericarditis: 35-50% of patients with uraemia and CKD. Indication for urgent dialysis.

Autoimmune: RA, rheumatic fever, SLE, scleroderma etc

Question 5

Describe the signs of acute pericarditis

Answer 5

Tachycardia, tachypnoea, fever
Pericardial friction rub: best heard with diaphragm at LSE with patient leaning forwards, at end of expiration
Loud high-pitched S3 (pericardial knock)

If constrictive:

• Right heart failure: raised JVP, ascite, hepatomegaly, Kussmaul sign
• Hypotension, pulsus paradoxus

Question 6

Which investigations help diagnose acute pericarditis?

Answer 6

FBC, U&Es, LFTs, CRP, CK, TnI

ECG is diagnostic*:

• Widespread saddle ST elevation
• Reciprocal ST depression in leads aVR and V1
• PR segment depression

CXR and echo: pericardial effusion
CT/MRI: thickened or inflamed pericardium

Question 7

What additional investigations help find the aetiology of acute pericarditis?

Answer 7

Virology
Blood cultures
Rheumatoid factor
ANA
Anti-dsDNA
Tuberculin testing
Sputum for acid-fast bacilli

Question 8

Outline the management of acute pericarditis

Answer 8

Treat any known underlying causes

Bed rest and oral NSAIDs

• High-dose aspirin, indometacin, or ibuprofen
• Aspirin post-MI: NSAID risk of myocardial rupture

Pericardial window
Pericardiectomy

Question 9

Define pericardial effusion and cardiac tamponade

Answer 9

Pericardial effusion: an abnormal accumulation of fluid within the potential space of the pericardial cavity. Commonly accompanies an episode of acute pericarditis.

Cardiac tamponade: Large pericardial effusion that compromises ventricular filling. This results in reduced CO, hypotension, and shock.

Question 10

Name 3 causes of acute pleural effusion

Answer 10

Trauma
Iatrogenic: cardiac surgery, catherisation, anticoagulant
Aortic dissection (Type A)
Spontaneous bleed
Cardiac rupture post-MI: think NSAIDs

Question 11

Name 3 causes of sub-acute pleural effusion

Answer 11

Malignancy
Idiopathic pericarditis
Uraemia
Infection (bacterial, viral, TB)
Radiation

Question 12

Describe the clinical features of pleural effusion and cardiac tamponade

Answer 12

Cardiac arrest
Hypotension
Confusion
Shock

If slow fluid accumulation: Dyspnoea, cough, dysphagia

Question 13

What signs are seen with cardiac tamponade?

Answer 13

Beck’s triad:

• Muffled heart sounds
• Hypotension
• Raised JVP

Tachycardia
Kussmaul’s sign: JVP increases on inspiration
Pulsus paradoxus: SBP, pulse decrease on inspiration

Question 14

How is pericardial effusion/cardiac tamponade investigated?

Answer 14

Echo: heart wobbles in pericardial effusion
ECG: low-voltage QRS complexes
CXR: large, globular heart, without pulmonary vein distension (unlike LV failure)

Pericardiocentesis: aspiration if TB, malignancy, or bacterial pericarditis (purulent) suspected
Pericardial Bx: TB still suspected when pericardiocentesis is not diagnostic

Question 15

How is pericardial effusion/cardiac tamponade managed?

Answer 15

Treat any underlying causes*
Most pericardial effusions resolve spontaneously

Cardiac tamponade is a medical emergency*:
-ABC, IV access and fluids, ECG, bloods, senior help

Pericardiocentesis to relieve pressure: USS or blind
-send fluid for microbiology and cytology
Pericardial drain enables temporary fluid release

Pericardial window if effusion re-accumulates: allows slow release of fluid into nearby tissues.

Question 16

Which causes of acute pericarditis result in constrictive pericarditis?

Answer 16

Tuberculosis*
Haemopericardium
Bacterial infection
Rheumatic heart disease

Question 17

Define constrictive pericarditis

Answer 17

Pericardium becomes thick, fibrous, and calcified to the point that it interferes with diastolic filling.

Question 18

Name one differential diagnosis of constrictive pericarditis

Answer 18

Restrictive cardiomyopathy

Question 19

What is the treatment of constrictive pericarditis?

Answer 19

TB likely cause:
No calcification: Anti-TB drugs only
Calcification: Anti-TB drugs + pericardiectomy

Non-TB, or no improvement with anti-TB drugs:
Complete resection of pericardium

Anti-TB treatment:

• 2 months of Rifampicin, Isoniazid (+ Vit B6), Pyrazinamide, Ethambutol
• Continue Rifampicin, Isoniazid (+Vit B6) for further 4 months