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Acute Pericarditis

by | 20 May, 2020

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Introduction

Acute pericarditis is inflammation of the pericardium. Classically, fibrinous material is deposited into the pericardial space and pericardial effusions commonly occur.

Causes

The commonest cause is viral infection.
  • Viral: coxsackie B, echovirus. Usually painful but short-term
  • Post-MI: occurs in 20% of patients in the first few fays after myocardial infarction. May also occur later in Dressler’s syndrome
  • Uraemic: due to irritation by accumulating toxins
  • Malignant: usually produces a haemorrhagic effusion. Usually from bronchial cancer, breast cancer and Hodgkin’s lymphoma.
  • Trauma
  • Connective tissue disorders e.g. Rheumatoid arthritis, systemic lupus erythematosus
  • Bacterial: can occur in septicaemia and post-operatively
  • Tuberculous
  • Fungal e.g. histoplasmosis

Clinical features

Symptoms

Chest pain with the following characteristics:

Site: central, well-localised

Character: sharp

Radiation: left shoulder, left arm, abdomen

Exacerbating factors: Breathing, movement, lying down

Relieving factors: Leaning forwards

Signs

  • Pericardial rub: usually heard at the left sternal edge during systole
  • Fever
  • Signs of right ventricular failure e.g. oedema, Kussmaul’s sign (rise of JVP on inspiration)
  • Pulsus paradoxus

Investigations

  • ECG: diagnostic. Shows saddle-shaped ST elevation in all leads without ST depression. May also show T wave inversion and PR depression
  • Chest x-ray: may show globular cardiac enlargement
  • Echocardiography: confirms pericardial effusion

Management

Treat the underlying cause. Viral causes recover within a few days-weeks. Consider:
  1. Analgesia: NSAIDs e.g. diclofenac
  2. Pericardiocentesis: for large, complicated effusions. May also be used for diagnostic purposes
Purulent pericarditis requires antibiotics, pericardiocentesis and (occasionally) surgical drainage.

Prognosis

Good. However, 20% of cases go on to develop idiopathic relapsing pericarditis.

Differential diagnosis

  • Angina
  • Pleurisy

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