Pericarditis & Effusions
Pericarditis
Differential Diagnosis
Infectious
- viral (Coxsackie, EBV, influenza, VZV, etc.)
- bacterial (pneumococcal, TB, etc.)
- fungal
Cardiac
- acute MI
- post-MI Dressler’s
Inflammatory
- DXR
- connective tissue disease (rheumatoid arthritis, SLE)
Systemic
- uraemia
- hypothyroidism
- malignancy
Other
- recurrent idiopathic
Clinical features
History
- Pleuritic chest pain relieved by sitting forward, dull central ache
Examination
- Pericardial friction rub on inspiration ('walking on freshly laid snow')
Investigations
- ECG (widespread saddle-shaped ST changes)
- ECHO (small effusion)
Management
- Analgesia (NSAIDs)
- If recurrent, then consider colchicine or steroids
Complications
- Effusion
- Tamponade
- Constrictive pericarditis
Pericardial Effusion
Definitions
- Effusion: accumulation of fluid in the pericardial space
- Tamponade: an effusion to the point where cardiac filling is compromised
Differential Diagnoisis
Caused by any of the causes of pericarditis:
Transudates
- heart failure
- liver failure
- nephrotic syndrome
- hypothyroidism
Exudates
- acute pericarditis
- metastatic Ca
Haemopericardium
- aortic dissection
- trauma
Clinical features
Symptoms
- SOB
Examination
- JVP (prominent x descent)
- Ewart’s sign (bronchial breathing @ L lung base if large effusion compresses Left Lower Lobe)
Tamponade
- Beck’s triad: low ABP, raised JVP, muffled HS
- Kussmaul’s sign (JVP on inspiration)
- pulsus paradoxus (>10mmHg ABP drop on inspiration)
Investigations
ECG
- low-voltage QRS
- electrical alternans (alternating QRS morphologies)
CXR
- globular heart
Echo
- diagnostic
Management
Effusion
- diagnostic pericardiocentesis (culture, Ziehl-Neelson stain (TB), cytology, etc.)
Tamponade
- therapeutic pericardiocentesis (percutaneous / surgical)
Constrictive pericarditis
- Chronic / recurrent pericarditis results in fibrosis
- Results in adherence of visceral and parietal pericardium
Leads to:
- decreased diastolic filling
- decreased cardiac output
Causes
Any cause of pericarditis.
Commonly...
- UK: unknown
- Elsewhere: TB
Clinical features
Right Ventricular Failure
- progressive shortness of breath
- oedema
- ascites
- raised JVP
Others
- Kussmaul’s sign
- soft apex beat
- quiet heart sounds
- diastolic pericardial knock
Investigations
- CXR (small heart, pericardial calcification)
- CT / MRI
- Cardiac catheterisation (angiography)
Management
- Diuretics (symptom relief)
- surgical excision
