Pericardial disease

Acute pericarditis

• Inflammation of the pericardium which may be primary of secondary to systemic disease
• Causes;
  • Viruses – coxackie, flu, EBV, mumps, varicella, HIV
  • Bacteria – pneumonia, rheumatic fever, TB
  • Fungi
  • MI, Dressler’s syndrome
  • Others – uraemia, RA, SLE, myxoedema, trauma, surgery, malignancy, radiotherapy
• Clinical features;
  • Chest pain, worse on inspiration and releived by leaning forward
  • May be a pericardial rub
  • May be fever
• Tests
  • ECG – classically shows saddled shaped ST segment
  • Bloods – FBC, ESR, U&Es, cardiac enzymes (troponin may be raised), viral serology, blood cultures and if indicated autoantibiodies, fungal precipitans, TFTs
  • CXR – cardiomegaly
  • Echo – if suspected pericardial effusion
• Treatment
  • Analgesia
  • Treat cause
  • Consider colchicines before steroids or immunosuppressants if relapse or continuing symptoms occur (15-40% do recur)

Pericardial effusion

• Accumulation of fluid in the pericardial sac
• Causes;
  • Any of the causes of pericarditis
• Clinical features;
  • Dyspnoea, raised JVP
  • Bronchial breathing at the left base (Ewart’s sign – large effusion pressing on the left lower lobe)
  • May be signs of cardiac tamponade
• Diagnosis
  • CXR – shows enlarged globular heart
  • ECG – shows low voltage QRS complexes and alternating QRS morphologies (electrical alterans)
  • Echo – shows an echo-free zone around the heart
• Management
  • Address the cause
  • Pericardiocentesis may be diagnostic or therapeutic
  • Send pericardial fluid for ZN stain/TB culture and cytology

Constrictive pericarditis

• The heart if encased in a rigid pericardium
• Causes – often unknown or any cause of pericarditis
• Clinical features
  • Mainly RHF with raised JVP, Kussmauls sign (JVP rising with inspiration), soft diffuse apex meat and quite heart sounds, S3, diastolic pericardial knock, hepatomegaly, ascites
• Tests
  • CXR – small heart +/- pericardial calcification
  • CT/MRI
  • Echo
  • Cardiac catheterization
• Management
  • Surgical excision

Cardiac tamponade

• Accumulation of pericardial fluid raises intra-pericardial pressure, hence poor ventricular filling and reduced cardiac output
• Causes
  • Any cause of pericarditis, aortic dissection, haemodialysis, warfarin, trans-septal puncture at cardiac catheterization, post cardiac biopsy
• Signs
  • Raised pulse, lowered BP, pulsus paradoxus, raised JVP, Kussmaul’/s sign, muffled heart sounds
• Diagnosis
  • Beck’s triad – falling BP, rising JVP, small quite heart
  • CXR – big globular heart (if >250ml of fluid)
  • ECG – low voltage QRS +/- electrical alterans
  • Echo – diagnostic – echo free zone >2cm, >1cm if acute around the heart, +/- diastolic collapse of the RA and RV
• Management
  • Urgent drainage, send fluid off for cytology and culture as before