Acute pericarditis

Classification and Aetiology

  • Largely based on the type of pericardial effusion produced by the inflammation
    • Serous
      • Usually secondary to connective tissue disorders e.g. Rheumatoid arthritis and SLE
    • Fibrous (most common)
      • Acute MI
      • Uraemia, radiation
      • RA, SLE
      • Viral infection
        • Coxsackie B virus
    • Purulent/Suppurative (i.e. bacterial infection)
      • Can be an extension of pulmonary disease (strep pneumoniae) or haematogenous spread or via trauma (other causes include spread from other local infections e.g. abscesses)
      • Tuberculosis can cause pericarditis
    • Haemorrhagic
      • Can be caused by tuberculosis or malignancy

Presentation

  • Classically retrosternal chest pain that radiates to the shoulders and neck
    • Worse on deep inspiration/expiration, movement, change of position (particularly lying flat), exercise and swallowing
    • Relieved by sitting forward
  • Fever
  • Pericardial friction rub (high-pitched superficial scratching or crunching- listen here) (occurs in 60-85%)
  • Other signs include tachypnoea/dyspnoea/orthopnoea; tachycardia; palpitations

Investigations

  • ECG
    • ST-elevation with upward concavity (ST-depression in aVR/V1)
      • Found throughout most leads
    • PR interval depression
    • Later, ST segment may normalise and T-waves may flatten and eventually invert
  • CXR
    • Flask-shaped cardiac silhouette
  • Echo
  • Blood
    • FBC (WCC/leukocytosis)
    • PV/CRP
    • U&Es (uraemia)
    • Cardiac enzymes
    • Blood cultures

Management

  • AspirinĀ and/or naproxen/indometacin
    • Colchicine or steroids may suppress symptoms but have not been shown to accelerate recovery
  • Viral cases will usually spontaneously resolve within a few days
  • Bacterial cases may require antibiotics, pericardiocentesis and possibly surgical drainage
  • NB Thrombolysis and anticoagulation is contraindicated because it may cause haemopericardium and cardiac tamponade (due to rupture and bleeding of vessels of the pericardium)

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