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Pericarditis

Pericarditis is the inflammation of the pericardial layers around the heart.

Pericarditis - National Heart Lung and Blood Institute

Most cases of are idiopathic (w/o an underlying cause). Underlying causes of it include:

  • Infection

  • Post-MI - Can occur as acute pericarditis or Dressler's syndrome after a myocardial infarction

    • Acute - 1-3 days after an MI due to the healing necrotic heart tissue interacting with the pericardium

    • Dressler syndrome - Weeks to months after an MI as an autoimmune response, triggering systemic inflammation (affects other serous membranes like the pleura = pleurisy)

  • Cancer

  • Autoimmune e.g. RA, SLE etc.

  • Drug-induced e.g. Methotrexate, Hydralazine

  • Uraemia – seen in ESRF (end-stage renal failure


Presentation

It's main presenting symptom is Pleuritic chest pain (>90%), which is:

  • Retrosternal

  • Radiates to the ridge of the trapezius

  • Relieved by sitting forwards


Patients may also present with fever and dyspnoea.


O/E - The signs that may be found include:

  • Pericardial rub – Due to friction between layers, typically loudest at the left lower sternal border, best heard on leaning forward

  • Signs of effusion

  • Beck’s Triad if cardiac tamponade


Investigations

ECG changes - Widespread saddle-shaped ST elevation, PR depression, Small QRS

  • Over the next 8 weeks, the ST normalises first, followed by the T waves flattening, then inverting, before normalising

“Pericarditis” © James Heilman (Licensed under CC-BY 4.0) https://creativecommons.org/licenses/by/4.0/


Other investigations to do include:

  • Basic obs – Checking for signs of haemodynamic compromise

  • Bloods - FBC (WCC, CRP), U&Es, LFTs, Troponin

  • Echo


Management

Idiopathic and Viral pericarditis:

  • 1st line is Exercise restriction, NSAIDs e.g. Ibuprofen and Colchicine

    • Aspirin is favoured instead if the patient also needs antiplatelet therapy.

    • Patient's should be co-prescribed a PPI

    • Colchicine should be used with caution in those with renal/hepatic impairment

  • 2nd line is with Steroids


N.B. Exercise restriction is recommended due to the risk of progression to myocarditis.


Bacterial pericarditis:

  • 1st line is IV Abx, and pericardiocentesis if purulent exudate is present

  • Pericardectomy is done if adhesions form or recurrent tamponade occurs


Constrictive Pericarditis

This is where the inflammation causes fibrosis and calcification, with adhesions forming between the pericardial layers. The pericardium can become stiff and inelastic to a point where it hinders diastolic filling (+ CO) = Constrictive Pericarditis. Highest risk of this is with bacterial pericarditis.


The changes that occur here are chronic, therefore the body is able to compensate. Patients may present with symptoms of fluid overload, and poor exercise tolerance/SOBOE. The definitive treatment here is a surgical pericardectomy.



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