Pericarditis Summary

Definition

  • Inflammation of the pericardium
  • Acute: <4-6 weeks duration
  • Clinical triad: chest pain, friction rub, ECG changes

Diagnostic Criteria

  • Requires ≥2 of 4 criteria:
  • Typical chest pain
  • Pericardial friction rub
  • Widespread ST elevation
  • Pericardial effusion

ECG Findings

  • Concave ST elevation in most leads
  • PR depression (except aVR/V1)
  • 4-stage evolution pattern

First-line Treatment

  • NSAIDs + PPI (4 weeks)
  • Colchicine (3 months)
  • Avoid steroids in viral cases

Emergency Indications

  • Cardiac tamponade
  • Purulent pericarditis
  • Large/symptomatic effusion

Common Causes

  • Idiopathic (most common)
  • Viral infections
  • Autoimmune disorders
  • Post-MI syndrome

Complications

  • Cardiac tamponade
  • Constrictive pericarditis
  • Recurrent pericarditis

Pericarditis

A comprehensive guide to inflammation of the pericardium

Definition

Pericarditis is an inflammation of the pericardium. The acute form is defined as new-onset inflammation lasting < 4-6 weeks. It can be either fibrinous (dry) or effusive with a purulent, serous, or haemorrhagic exudate.

Clinical Triad: Characterized by chest pain, pericardial friction rub, and serial electrocardiographic changes. Acute pericarditis is more common in adults (typically between 20 to 50 years old) and in men.

Causes

Common Causes

  • Idiopathic
  • Viral infections:
    • Coxsackievirus, echovirus, mumps
    • Epstein-Barr virus, cytomegalovirus
    • Varicella, rubella, HIV, Parvovirus B19
  • Systemic autoimmune disorders:
    • SLE, rheumatoid arthritis
    • Systemic sclerosis, reactive arthritis
    • Familial Mediterranean fever
    • Systemic vasculitides
    • Inflammatory bowel disease

Less Common Causes

  • Bacterial/fungal/parasitic infections
  • Secondary immune processes:
    • Rheumatic fever
    • Postcardiotomy syndrome
    • Post-MI syndrome
  • Diseases of surrounding organs:
    • Acute MI, myocarditis
    • Paraneoplastic syndromes
  • Metabolic disorders:
    • Uraemia, myxoedema
  • Post-surgery, radiotherapy or trauma
  • Malignancy
  • Drug-related:
    • Hydralazine, procainamide
    • Isoniazid, chemotherapy drugs

Clinical Features

Acute pericarditis is a clinical diagnosis. The diagnosis is confirmed in the presence of at least 2 of the 4 clinical criteria:

  1. Typical chest pain
  2. Pericardial friction rub
  3. Widespread ST elevation
  4. Pericardial effusion

Symptoms

  • Chest pain: Constant, pleuritic central chest pain that:
    • Worsens on coughing or lying supine
    • Relieved when sitting up or leaning forwards
    • Radiates to one or both trapezius ridges (phrenic nerve innervation)
  • Prodrome of myalgias and malaise (especially in young adults)
  • High or spiking fever suggests infectious cause

Signs

  • Pericardial friction rub: Best heard at left lower sternal border with patient leaning forward at end-expiration
  • Pericardial effusion: Distant heart sounds with quiet precordium

ECG Findings

  • Classic changes:
    • Global upwardly concave ST-segment (J-point) elevations with PR segment depressions in most leads
    • J-point depression and PR elevation in leads aVR and V1
  • ECG evolution:
    1. Stage 1: ST elevation and upright T-waves
    2. Stage 2: Resolves to normal
    3. Stage 3: T-wave inversion
    4. Stage 4: Returns to normal

Other Tests

Test Findings
FBC Leucocytosis with left shift (purulent/infectious)
Urea Elevated (>21.4 mmol/L suggests uraemic cause)
ESR/CRP Elevated (inflammatory state)
Troponins May be elevated (myocardial involvement) but nonspecific
Chest x-ray Water bottle-shaped cardiac silhouette (large effusion); may show lung pathology
Pericardiocentesis For purulent pericarditis (urgent); test fluid for pathogens
Echocardiography Detects effusion, tamponade; differentiates from ACS
Chest CT Diagnoses constrictive pericarditis or effusion

Differential Diagnosis

  • Myocardial infarction or ischaemia
  • Pulmonary embolism
  • Pneumonia
  • Pneumothorax
  • Costochondritis

Management

General Approach: Treatment is directed at any identified underlying disorder with supportive management for symptom relief. Hospitalization is generally recommended to determine aetiology, observe for complications, and gauge treatment response.

Pericardial Effusion

  • Pericardiocentesis indicated for:
    • Clinical tamponade
    • High suspicion of purulent/neoplastic pericarditis
    • Large or symptomatic effusion
  • Drain effusion completely and analyze fluid:
    • Glucose, protein, lactate dehydrogenase
    • Cell count, microscopy
    • Bacterial/viral culture
    • Cytological examination

Purulent Pericarditis

Urgent Management Required

  • Immediate percutaneous pericardiocentesis with pericardial cavity rinsing
  • IV antibiotics:
    • Empiric: Anti-staphylococcal + aminoglycoside
    • Tailor based on culture results
  • Continue antibiotics until fever and infection signs resolve
  • NSAID + PPI for symptom management (4 weeks)
  • Surgical drainage may be needed for:
    • Dense adhesions/loculations
    • Persistent bacteraemia
    • Recurrent tamponade
    • Constrictive physiology

Non-Purulent Pericarditis

  • First-line:
    • NSAIDs (4 weeks) + PPI
    • Colchicine (adjunct, improves response, prevents recurrences) - continue for 3 months
  • Corticosteroids:
    • Consider if no response after 2 weeks or NSAID contraindicated
    • Avoid in viral pericarditis (risk of reactivation)
    • Use for autoimmune conditions
  • Treat underlying cause:
    • Tuberculous: 4-6 weeks anti-TB therapy
    • Uraemic: Intensive dialysis (1-2 weeks)
    • Autoimmune: Corticosteroids/immunosuppressants
    • Neoplastic: Radiotherapy/chemotherapy/surgery
    • Viral: Consider antiviral therapy

Complications

Pericardial Effusion with Cardiac Tamponade

Life-Threatening Emergency

  • Pathophysiology: Increased intrapericardial pressure compresses cardiac chambers, limiting filling
  • Symptoms: Dyspnoea, chest pain
  • Signs:
    • Tachycardia, tachypnoea, hypotension
    • Elevated JVP, distended neck veins
    • Kussmaul's sign (↑ venous pressure with inspiration)
    • Pulsus paradoxus
  • ECG: Low QRS voltages, electrical alternans
  • Management:
    • Urgent echocardiography
    • Emergency pericardiocentesis (echo-guided)
    • Surgical drainage for:
      • Traumatic haemopericardium
      • Type A aortic dissection
      • Ventricular free wall rupture post-MI

Chronic Constrictive Pericarditis

  • Pathophysiology: Dense scar encases heart, interfering with ventricular filling
  • Presentation: Right heart failure (fatigue, edema, ascites)
  • Timing: Typically 3-12 months after pericardial insult
  • Causes: Cardiac surgery, radiotherapy, idiopathic
  • Treatment: Surgical pericardial resection

Key Points

  • Diagnosis requires ≥2 of: characteristic pain, friction rub, ECG changes, effusion
  • ECG shows concave ST elevation with PR depression (except aVR/V1)
  • Purulent pericarditis requires immediate drainage and antibiotics
  • First-line treatment: NSAIDs + colchicine (3 months)
  • Avoid steroids in viral pericarditis unless autoimmune cause
  • Monitor for complications: tamponade (emergency) and constriction (chronic)