Acute Pericarditis

• What is acute pericarditis?


  Inflammation of the pericardial sac

  Lasts for less than 4-6 weeks

  Most common type of pericardial disease
• Acute pericarditis can be fibrinous (dry) or effusive with fluid buildup (purulent, serous, or hemorrhagic).
• What are the functions of the pericardium?


  Protects & stabilises heart's position

  Controls cardiac filling & limits excessive expansion

  Balances pressure between the heart's chambers
• What are the signs & symptoms of acute pericarditis?


  Chest pain (often retrosternal)

  Pericardial rub

  Fever

  Myalgia
• What is a pericardial rub?


  Superficial scratchy or squeaking sound

  Heard best at L sternal edge & at cardiac borders with pt leaning forward at end-expiration
• What are the RFs for acute pericarditis?


  Male

  Age 20-50

  Transmural MI

  Cardiac surgery

  Neoplasm

  Viral & bacterial infection

  Uraemia

  Dialysis treatment

  Systemic autoimmune disorders
• What are the Inx for acute pericarditis?

  Obs

  Full Hx & examination

  ECG

  Bloods (FBC, U&Es, LFTs, CRP, troponin, creatinine kinase, cultures, autoimmune screen & viral screen)

  CXR

  Echo

  Chest CT

  Cardiac MRI

  Pericardiocentesis

  Pericardial biopsy (rare)
• What would an ECG show in acute pericarditis?


  Saddle-shaped ST segments

  PR depression in most leads

  PR elevation in leads aVR & V1
• Why are LFTs important in acute pericarditis?


  Elevated with liver congestion

  Liver congestion may be present if developing cardiac tamponade
• What would a CXR show in acute pericarditis?


  Usually normal

  If large pericardial effusion, CTR will be increased
• An echo should always be organised for any pt with suspected acute pericarditis.

  If suspect cardiac tamponade -> should be performed urgently at bedside
• What are the indications for pericardiocentesis?


  Suspected...

  • Cardiac tamponade
  • Purulent pericarditis
  • Neoplastic pericarditis
  • Large or symptomatic pericardial effusion in pts with non-purulent pericarditis
• What are the DDx of acute pericarditis?


  PE

  MI/ischaemia

  Pneumonia

  PTX

  Costochondritis

  Myocarditis
• What are the possible complications of acute pericarditis?


  Constrictive pericarditis

  • chronic inflammation -> thickened pericardium, restricting heart filling & function over time

  Cardiac tamponade
• What is the treatment of idiopathic or viral non-purulent acute pericarditis?


  NSAIDs

  PPI

  Colchicine

  Exercise restriction

  Consider corticosteroid
• What is the treatment of not idiopathic or viral non-purulent acute pericarditis?


  Treat underlying cause

  NSAIDs

  PPI

  Colchicine

  Exercise restriction

  Consider corticosteroid
• What is the treatment of purulent acute pericarditis?


  IV Abx

  Specialist management (pericardiocentesis or surgical pericardial intervention)
• What is purulent pericarditis?


  Inflammation of the pericardium with pus accumulation (bacterial involvement).
• What is fibrinous/serofibrinous pericarditis?


  Inflammation of the pericardium with fibrin deposition.
• Pathphys of acute pericarditis


  Triggering event (viral infection, post-MI syndrome, systemic inflammatory diseases) → acute inflammatory response in pericardium → release of pro-inflammatory cytokines (IL-1, IL-6 & TNF-a) → recruits immune cells to site of injury → increased vascular permeability (due to vasoactive histamine & bradykinin) → exudation of plasma proteins & fluid into pericardial space → effusion & potentially cardiac tamponade (if unchecked)
• What is the treatment of recurrent acute pericarditis?


  NSAIDs

  PPI

  Colchicine (do not use if pt has TB pericarditis)

  Treat underlying cause

  Exercise restriction

  Consider corticosteroid, immunosuppressant & pericardiectomy