Pericarditis
DEFINITION
Inflammation of the pericardium, may be acute, subacute or chronic.
AETIOLOGY
- . Idiopathic;
- . infective (commonly, coxsackie B, echovirus, mumps virus, streptococci, fungi, staphylococci, TB);
- . connective tissue disease (e.g. sarcoid, SLE, scleroderma);
- . post-myocardial infarction (24–72 h) in up to 20% of patients;
- . Dresslers syndrome (weeks to months after acute MI);
- . malignancy (lung, breast, lymphoma, leukaemia, melanoma);
- . mtabolic (myxoedema, uraemia);
- . radiotherapy;
- . thoracic surgery;
- . drugs (e.g. hydralazine, isoniazid).
EPIDEMIOLOGY
Uncommon. The clinical incidence is <1 in 100 hospital admissions. More common in males.
HISTORY
Chest pain:
Sharp and central, which may radiate to neck or shoulders. Aggravated by coughing, deep inspiration and lying flat. Relieved by sitting forward.
Dyspnoea, nausea.
EXAMINATION
Fever, pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration), heart sounds may be faint in the presence of an effusion.
Cardiac tamponade:
" JVP, # BP and muffled heart sounds (Beck s triad). Tachycardia, pulsus paradoxus (reduced systolic BP by >10 mmHg on inspiration).
Constrictive pericarditis (chronic):
" JVP with inspiration (Kussmauls sign), pulsus paradoxus, hepatomegaly, ascites, oedema, pericardial knock (rapid ventricular filling), AF.
INVESTIGATIONS
ECG:
Widespread ST elevation that is saddle-shaped.
Echocardiogram:
For assessment of pericardial effusion and cardiac function.
Blood:
FBC, U&E, ESR, CRP, cardiac enzymes (usually normal). Where appropriate: blood cultures, ASO titres, ANA, rheumatoid factor, TFT, Mantoux test, viral serology.
CXR:
Usually normal (globular heart shadow if >250 mL effusion). Pericardial calcification can be seen in constrictive pericarditis (best seen on lateral CXR or CT).
MANAGEMENT
Acute:
Cardiac tamponade treated by emergency pericardiocentesis.
Medical:
Treat the underlying cause, NSAIDs for relief of pain and fever.
Recurrent:
Low-dose steroids, immunosuppressants or colchicine.
Surgical:
Surgical excision of the pericardium (pericardiectomy) in constrictive pericarditis.
COMPLICATIONS
Pericardial effusion, cardiac tamponade, cardiac arrythmias.
PROGNOSIS
Depends on underlying cause. Good prognosis in viral cases (recovery within 2 weeks), poor in malignant pericarditis. Pericarditis may be recurrent (particularly in those
caused by thoracic surgery).
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