Pericarditis
ACUTE
minor pathophysiologic consequences unless with effusion
Large effusions impair filling as pericardium is non-compliant (stiff)
Tamponade > shock > death
Types of effusion:
Hx
Chest pain: sharp/stabbing, positional, radiating, worse with inspiration, and relieved by sitting upright or prone
fever
dyspnea
abdominal pain
vomiting
Ex
Muffled or distant heart sounds
tachycardia, hypotension
narrow pulse pressure
Systemic venous hypertension (Oedema, Raised JVP, Hepatomegaly, Ascities)
pericardial friction rub
Pulsus paradoxus (SBP drop >10 mm Hg with inspiration)
Ix
ECG nonspecific: Low voltage QRS if effusion, other PR/ST/T changes
CXR: cardiomegaly (Erlenmeyer flask or Water bottle)
ECHO: most sensitive, see compression/collapse of RA/RV
Dx
Effusion on ECHO = pericarditis
if diminished myocardial contractility or valvular dysfunction = myocarditis
Infectious
Non-infectious (serus)
Rx
NSAIDs
Pericardiocentesis if tamponade
Pericardial window if chronic/relapsing
CONSTRICTIVE
Rarely chronic pericardial inflammation can result in fibrosis, calcification, and thickening of the pericardium
Impairs cardiac distensibility and filling
Causes
Ex
As for acute
Pericardial knock
Ix
CXR: as for acute + pericardial calcifications
Abnormal LFT, low albumin, protein, lymphocytes
ECHO difficult to differential constrictive pericarditis from restrictive cardiomyopathy
CT / MRI / exploratory thoracotomy useful adjuncts
Rx
Extensive pericardiectomy
minor pathophysiologic consequences unless with effusion
Large effusions impair filling as pericardium is non-compliant (stiff)
Tamponade > shock > death
Types of effusion:
- serous/transudative
- exudative/purulent
- fibrinous
- hemorrhagic
Hx
Chest pain: sharp/stabbing, positional, radiating, worse with inspiration, and relieved by sitting upright or prone
- DDx Pleurisy
fever
dyspnea
abdominal pain
vomiting
Ex
Muffled or distant heart sounds
tachycardia, hypotension
narrow pulse pressure
Systemic venous hypertension (Oedema, Raised JVP, Hepatomegaly, Ascities)
pericardial friction rub
Pulsus paradoxus (SBP drop >10 mm Hg with inspiration)
Ix
ECG nonspecific: Low voltage QRS if effusion, other PR/ST/T changes
CXR: cardiomegaly (Erlenmeyer flask or Water bottle)
ECHO: most sensitive, see compression/collapse of RA/RV
Dx
Effusion on ECHO = pericarditis
if diminished myocardial contractility or valvular dysfunction = myocarditis
Infectious
- Viral aka acute benign (usually benign and spontaneously resolving) Rx symptomatic with NSAIDs
- enteroviruses
- influenza
- adenovirus
- respiratory syncytial virus
- parvovirus
- Bacterial (usually secondary to pneumonias, epiglottitis, meningitis, or osteomyelitis)
- Hi
- Pneumococcal
- TB (if HIV pos and in endemic area)
Non-infectious (serus)
- Immune-complex mediated
- Post meningococcus / haemophilus
- rheumatology (connective tissue)
- SLE (autoimmune)
- sJIA (autoimmune)
- Acute Rheumatic Fever (post GAS)
- Chronic renal failure
- Hypothyroidism
- Neoplastic
- Hodgkin disease, lymphomas, and leukemia
- Radiotherapy (acute then later constrictive)
- Postpericardiotomy syndrome (antiheart antibodies)
Rx
NSAIDs
Pericardiocentesis if tamponade
Pericardial window if chronic/relapsing
CONSTRICTIVE
Rarely chronic pericardial inflammation can result in fibrosis, calcification, and thickening of the pericardium
Impairs cardiac distensibility and filling
Causes
- chronic pericarditis
- cardiac surgery
- radiotherapy (Hodgkin disease or lymphoma)
Ex
As for acute
Pericardial knock
Ix
CXR: as for acute + pericardial calcifications
Abnormal LFT, low albumin, protein, lymphocytes
ECHO difficult to differential constrictive pericarditis from restrictive cardiomyopathy
CT / MRI / exploratory thoracotomy useful adjuncts
Rx
Extensive pericardiectomy