Aetiology (ABCD)

• Autoimmune: ARF, sarcoidosis, SLE, post MI, vasculitis, RA
• Bacteria/virus (virus>bact): TB/staph/strep, influenza/mumps/coxsackie
• Cancer (mets): Melanoma, breast, lung
• Drugs: tetracycline, chemo

Clinical Features

Presentation

• Sharp retrosternal pain; can radiate neck, jaw, arm
• worsened w/ inspiration/swallow/cough or laying flat
• improved when leaning forward

Examination

• Vitals
  • Tachycardia, hypotension (narrow pulse pressure – obstructive shock).
  • Pulsus paradoxus: neg intrathoracic P increases → inc venous return to heart → RV distends → interventricular septum bulges into LV → dec LV end diastolic volume → dec SV & arterial pressure. This is pronounced in pericarditis.
• Cardiovascular:
  • Pericardial rub(creaking leather) @ lower L sternal border w/ patient upright + forward.
  • Non-palpable apex
  • Kussmaul sign: inc JVP w/ inspiration (poor RV filling)
  • Possible associated tamponade (Beck’s Triad): JVP, muffled heart sounds, dec BP.
• Respiratory:
  • Tachypnoea
  • Decreased breath sounds
• Abdo:
  • Hepatosplenomegaly
• Other:
  • Possible low fever
  • Oedema

Investigations

• Echo/CT/CMRI: increased fluid in pericardial sac

• ECG:

  • Stages:
    • 1: Diffuse ST elevation + PR depression; ST depression + PR elevation in aVR
    • 2: Resolution above & T flattens
    • 3: T inversion
    • 4: Resolution

  

  Spoddick’s sign in II lateral leads (downslope of TP segment) Electrical alternans w/ small QRS

  

• CXR: boot-shaped heart w/ cardiothoracic ratio 0.5 (also cardiomyopathy).

• Troponin: depends if MI

• CRP: can be inc (non-specific)

• FBC: leukocytosis

• Tuberculin, RF, ANA

Management

• NSAIDs: ibuprofen (+PPI if >65, peptic ulcer)
  • or aspirin
• Colchicine: 500mg PO 1/2x daily for 3 months to decrease recurrence
• Shock?
  • Yes: pericardiocentesis
  • No: surgical pericardial window + drain