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Pericarditis

1. ACUTE PERICARDITIS

  • Normal pericardium contains 50ml of fluid
  • Functions – lubricates the heart, limits distension, protects heart from infection/damage, aids filling of ventricles

Etiology and Pathology

  • See box
  • Pericarditis can lead to pericardial effusion
  • Can be fibrinous, serous, haemorrhagic, purulent pericarditis
    • Fibrinous exudates can lead to adhesion formation (restrictive motion)
    • Serous pericarditis can produce a large effusion of turbid, straw coloured fluid with high protein content
    • Hemorrhagic effusion – due to malignant disease, esp. ca of breast, bronchus
    • Purulent pericarditis – complication of septicaemia, penetrating injury or direct spread of an intrathoracic infection
  • Dressler’s syndrome – pericarditis 2o to myocardial/pericardial damage
    • Occurs at least 2 weeks after the MI

Clinical features

  • Retrosternal pain – radiates to shoulder and neck
    • Aggravated by deep breathing, movement, exercise
  • Low grade fever (LGF)
  • Pericardial friction rub – high pitched scratching noise
    • Diagnostic of pericarditis

Diagnosis

  • Based on CF and history
  • ECG
    • ST elevation (saddle shaped)
    • PR interval depression – specific for acute pericarditis
  • FBC – leuko/lymphocytosis due to bacterial/viral infection
  • CRP/ESR – inflammatory marker

Treatment

  • Simple viral pericarditis – colchicine
  • Oral NSAIDs/aspirin for pain
  • Purulent pericarditis – ABs

2. PERICARDIAL EFFUSION

  • Puts pressure on the ventricles – compromises pumping
  • Cardiac tamponade
    • Defined as acute HF due to compression of the heart by a large effusion
    • CF – ↑JVP, hypotension, pulsus paradoxus, oliguria
  • Diagnosis
    • ECG – low QRS voltage. Alternating amplitude of QRS due to to-and-fro motion of the heart within the sac
    • CXR – globular appearance
    • Echo – most useful as directly shows tamponade
    • Pericardiocentesis  – if infectious cause is suspected e.g. TB
      • Needle inserted below xiphoid process, directed upwards towards L shoulder – under echo guidance
      • Complications of procedure – arrhythmias, cor. artery damage, bleeding & exacerbation of tamponade
  • Treatment
    • Tx underlying cause
    • If effusion is rapidly forming do pericardiocentesis to avoid tamponade
    • Fenestration – for recurring effusion (mostly due to malignancy), creates a ‘window’ within the pericardium

3. TUBERCULOUS PERICARDITIS

  • Tuberculous pericardial effusion is a common presentation of AIDS in Africa
  • Pericardium becomes thick – leads to constriction and tamponade
  • Clinical features – chronic malaise, WL, LGF
  • Diagnosis – pericardiocentesis
  • Treatment – anti-TB regime
  • + 3 months of prednisolone

4. CHRONIC CONSTRICTIVE PERICARDITIS

  • Due to progressive thickening, fibrosis and calcification of the pericardium
    • Heart is enclosed in a ‘solid shell’ – cannot fill properly
  • Often follows an attack of tuberculous pericarditis
  • Can also be a complication of viral or purulent pericarditis, haemopericardium, rheumatoid arthritis

Clinical features – see box

  • Symptoms of systemic venous congestion
  • AF
  • Ascites and hepatomegaly

Diagnosis

  • CXR – pericardial calcification
  • Doppler echo – to distinguish from restrictive cardiomyopathy

Treatment

  • Surgical resection of diseased pericardium – but this is a high risk procedure

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