Pericarditis

Acute inflammation of the pericardium


Pericardium

• Aids efficiency by aiding filling of the heart and distribution of hydrostatic forces
• Acts as barrier against extension of malignancy and infection
• Anchors heart to sternum, diaphragm, and costal cartilages

Pathogenesis

• During acute inflammation, there is pericardial vascularisation and infiltration with leukocytes
• Fibrinous reaction leads to exudate and adhesions within the pericardial sac, and serous or haemorrhagic effusion may develop

Common Causes

• Viral
• Coxsackie virus
• Rheumatological
• SLE
• Drugs
• Hydralazine
• Procainamide
• Other
• Myocardial infarction
• Postmyocardial infection syndrome (i.e. Dressler's syndrome)

Prevalence

• Males more than females
• Adults more than children
• 0.1% of admissions

Symptoms

• Dull, sharp, burning, or pressing
• Either barely perceptible or up to a severe level
• Felt in the substernal or precordial region
• Radiating to the neck, trapezius ridge (left) and shoulders
• Aggravated by inspiration, swallowing, coughing, and lying flat
• Non-productive cough, chills, and weakness

Signs

• Pericardial friction rub on auscultation
• Pleural effusion may be present
• Tachypnoea, tachycardia and fever
• Dyspnoea and orthopnoea when cardiac tamponade occurs

Differential diagnoses

• MI or myocardial ischaemia
• Pleuritic pain
• Pulmonary infarction
• Peptic ulcer disease or oesophagitis

Investigations

• ECG - Saddle shaped ST elevation throughout
• Note 4 stages of progression (stage 4 is resolution of T wave inversion)
• CXR
• Blood tests
• Echocardiography
• CT or MR scanning
• Pulse oximetry waveform
• Pericardiocentesis for drawing fluid from the pericardial space under echocardiographic monitoring

Management

• Exclude other major causes of such a presentation
• Assess for haemodynamic instability
• Assess for progression to other complications (like cardiac tamponade)
• To be assessed for development of adverse prognostic factors
• Fever of more than 38
• Trauma
• Anticoagulation therapy
• Myocarditis
• Subacute onset
• Immunosuppression
• Severe effusion with tamponade

Outpatient management

• NSAIDs
• Colchicine
• Cessation of causative factors (drugs?)

Complication management

• Immediate pericardiocentesis for cardiac tamponade
• Pericardiac resection for severe chronic pericarditis
• Balloon pericardiotomy, surgical pericardial window, or sclerosis with tetracycline for Recurrent symptomatic effusive pericarditis
• NSAIDs and Colchicine

Prognosis

• Depends on cause
• Viral or other less severe causes is self limiting and over a course
• Neoplasms may follow a worse course and end in death