Acute Pericarditis ✅

Related Subjects: | Assessing Breathlessness | Assessing Chest Pain | Pericardial Effusion and Tamponade | Constrictive Pericarditis | Colchicine |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro-oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion Tamponade

❤️ Acute pericarditis = inflammation of the pericardial sac. Classic ECG: widespread concave (“saddle-shaped” ⛰️) ST elevation + PR depression 📉. Presentation ranges from mild chest pain to tamponade or myopericarditis.

🌍 Epidemiology

• ~5% of chest pain presentations in the ED 🏥
• Complications (tamponade, constriction) occur in ~5%
• Most common in young adults (viral/post-viral)

🩺 Clinical Features

• Sharp, pleuritic chest pain ❤️🔥 (worse lying down, improves sitting forward 🪑)
• Fever 🤒, malaise, myalgia
• Pericardial rub 🎧: 3 components, squeaky at LSB
• Distant heart sounds → suggestive of effusion 💧
• Dyspnoea if effusion or tamponade
• Assess for tamponade: raised JVP, hypotension, pulsus paradoxus >10–15 mmHg 🚨

❓ Differential Diagnosis

• Acute coronary syndrome (MI) ❤️‍🔥
• Myocarditis 🫀
• Aortic dissection 🌪️
• Pneumonia 🌬️, pulmonary embolism 🩸
• Gastroesophageal pain 🍔🔥
• Musculoskeletal pain 💪

🧬 Causes

🩺 ECG Changes in Acute Pericarditis: The hallmark ECG pattern is widespread concave (“saddle-shaped”) ST-segment elevation accompanied by PR-segment depression in most leads (except aVR, which may show PR elevation). The changes typically evolve through four stages:
1️⃣ Stage 1: Acute – widespread ST elevation + PR depression (hours to days).
2️⃣ Stage 2: ST and PR segments begin to normalize.
3️⃣ Stage 3: T-wave inversion develops once ST segments normalize.
4️⃣ Stage 4: ECG gradually returns to baseline.
Other features may include low-voltage QRS if there is pericardial effusion and transient arrhythmias. Unlike STEMI, the ST elevation in pericarditis is diffuse and concave rather than localized and convex, and reciprocal changes are generally absent. Serial ECGs are recommended to monitor evolution and detect complications.

🔎 Investigations

• Bloods: FBC, U&E, CRP/ESR ↑, troponin if myopericarditis
• ECG: 4 stages – 1️⃣ widespread concave ST ↑ + PR ↓, 2️⃣ normalization, 3️⃣ T inversion, 4️⃣ T wave normalization
• CXR: usually normal; ± cardiomegaly if effusion
• Echocardiography: assess effusion, tamponade, LV function
• Cardiac MRI: myocardial inflammation, oedema (Lake Louise criteria)
• Pericardial fluid analysis: cytology, culture, TB PCR if effusion present
• Autoimmune/serology as indicated (ANA, dsDNA, RF, viral serologies)

📊 Prognostic Predictors

• Major: Fever >38°C, CRP elevation, subacute onset, large effusion, tamponade, NSAID non-response
• Minor: Immunosuppression, trauma, anticoagulants, myopericarditis

🩺 Management (NICE-compliant)

• Bed rest 🛌 until symptom resolution, avoid strenuous exercise until CRP, ECG, echo normalize (≥3 months for athletes)
• First-line pharmacologic: NSAID (e.g., Ibuprofen 400–600mg TDS) + PPI prophylaxis
• Colchicine 0.5–1 mg/day for 3 months to reduce recurrence
• Second-line: Low-dose corticosteroids if NSAID/colchicine contraindicated (exclude infection first)
• Recurrent pericarditis: escalate to IVIG 💉, Anakinra 🧬, or azathioprine 💊 if steroid-dependent or refractory
• Severe / life-threatening effusion: pericardiocentesis or pericardiectomy 🛠️
• Infective pericarditis: targeted antibiotics/antifungals/anti-TB therapy
• Neoplastic pericarditis: oncology referral, chemo/radiotherapy as indicated
• Post-MI (Dressler): NSAIDs + colchicine; avoid anticoagulants if large effusion
• Uraemic pericarditis: intensify dialysis; NSAIDs with caution; colchicine if tolerated
• Monitor: ECG, CRP, echo; treat complications (tamponade, arrhythmia) promptly

📚 References / Guidelines

• 2015 ESC Guidelines on Pericardial Disease
• NICE Clinical Knowledge Summary – Chest Pain
• Adler Y et al. Eur Heart J. 2015;36:2921–2964

🧑‍⚕️ Case Examples - Acute Pericarditis

• Case 1 (Viral): 🦠 25-year-old man with pleuritic chest pain relieved sitting forward. ECG: widespread ST elevation + PR depression. CRP mildly raised. Management: NSAID + colchicine, rest, monitor for effusion.
• Case 2 (Post-MI Dressler’s): ❤️‍🔥 60-year-old man, 3 weeks post-STEMI, fever, pericardial rub, effusion. Management: NSAID + colchicine, avoid anticoagulation if large effusion, monitor echo.
• Case 3 (Uraemic): 🧬 48-year-old man with CKD5 on dialysis, chest pain, pericardial rub, small effusion. Management: Intensify dialysis, cautious NSAID/colchicine, monitor for tamponade.

Additional related clinical topics

Constrictive Pericarditis ❤️

📖 About

• Constrictive pericarditis = rigid pericardium → heart trapped in a “small rigid box.”
• ❌ Restricts normal diastolic filling → impaired cardiac output.
• JVP: prominent x descent; y descent prominent (lost in tamponade).
• Key haemodynamics: dip & plateau / “square root sign” on pressure tracings.

🦠 Causes

• Idiopathic / Post-viral 🌐 → most common in developed countries.
• Tuberculosis 🦠 → commonest cause worldwide, esp. developing countries.
• Post-surgical or Post-radiation 🏥 → scarring after cardiac surgery or mediastinal radiotherapy.
• Inflammatory / Autoimmune 🤲 → RA, SLE, systemic autoimmune disease.
• Metabolic 💉 → Uraemia, trauma.
• Malignancy 🎗️ → primary pericardial tumours or secondary invasion.
• Drugs 💊 → hydralazine, procainamide, methysergide.

🧬 Pathophysiology

• Ventricular filling impaired in mid/late diastole.
• All diastolic pressures equalise (RA, RV, LA, LV).
• Dip and plateau waveform = rapid early filling then abrupt halt ⏹.

🩺 Clinical Features

• 📉 Symptoms: fatigue, weakness, ascites, breathlessness, orthopnoea.
• 🫀 Signs:
  • Soft heart sounds, impalpable apex beat.
  • Signs of right heart failure: hepatomegaly, ascites, pleural effusion.
  • Raised JVP with both x & y descents (Friedreich’s sign).
  • Kussmaul’s sign → JVP rises with inspiration (normally falls).
  • Pericardial knock → early diastolic sound (mimics S3).
  • Pulsus paradoxus (more classic in tamponade, but can occur here).
• ❌ Pulmonary oedema suggests another diagnosis (think restrictive cardiomyopathy).

💡 Key exam pearl: differentiate from restrictive cardiomyopathy (myocardial disease) and cardiac tamponade (fluid compression). This may need multimodal imaging and haemodynamics.

🔎 Investigations

• 🧪 Bloods: FBC, U&E, CRP → look for TB, uraemia, inflammation.
• 📷 CXR: pericardial calcification, pleural effusions.
• 📉 ECG: low QRS voltage, widespread T wave flattening/inversion, P mitrale.
• 🩻 Echo: thickened, bright pericardium ± septal bounce.
• 🧭 Cardiac catheterisation: square root sign (early dip + plateau).
• 🧲 CT / MRI: confirm thickened or calcified pericardium, assess extent.
• 🔬 Pericardial biopsy if unclear (TB, malignancy).

🛠️ Management

• Medical 💊:
  • Diuretics → relieve fluid overload (symptomatic only).
  • NSAIDs or steroids if active inflammation present.
• Surgical 🔪:
  • Pericardiectomy = definitive treatment.
  • High-risk surgery but often curative in severe symptomatic cases.

📚 References

• ESC Guidelines – Pericardial Diseases (2015)

Cases - Constrictive Pericarditis

• Case 1 - Post-Tuberculosis Pericarditis: A 45-year-old man from South Asia presents with progressive breathlessness, abdominal distension, and leg swelling. On exam: raised JVP with prominent y descent, hepatomegaly, ascites, and peripheral oedema. Heart sounds are quiet, and a pericardial knock is heard in early diastole. CXR: pericardial calcification. Echocardiography: septal bounce and ventricular interdependence. Diagnosis: Constrictive pericarditis secondary to TB infection. Management: Optimise with diuretics for fluid overload; definitive treatment is pericardiectomy in suitable patients.
• Case 2 - Post-Cardiac Surgery Patient: A 62-year-old woman presents 1 year after CABG surgery with exertional dyspnoea, fatigue, and ankle oedema. Examination: raised JVP with Kussmaul’s sign, hepatomegaly, ascites. ECG shows low-voltage QRS. Echocardiography: thickened pericardium with abnormal ventricular filling. Cardiac catheterisation: equalisation of diastolic pressures in all four chambers. Diagnosis: Constrictive pericarditis post-cardiac surgery. Management: Symptomatic relief with diuretics initially; surgical pericardiectomy is the only curative therapy.

Teaching Commentary ❤️

Constrictive pericarditis occurs when the pericardium becomes fibrosed and rigid, impairing diastolic filling and mimicking right heart failure. Causes include tuberculosis, previous cardiac surgery, radiation, and idiopathic/viral. Classic findings: raised JVP with rapid y descent, Kussmaul’s sign, ascites, hepatomegaly, peripheral oedema, and a pericardial knock. Echo and CT/MRI can confirm thickened, calcified pericardium. Management is mainly supportive with diuretics, but definitive treatment is pericardiectomy in patients with severe, persistent symptoms.