PERICARDITIS
Acute pericarditis = inflammation of the heart sac, aka pericardium, with acute-onset symptoms and ECG features
Chronic pericarditis = >3 months of inflammation involving the pericardium, usually following an acute episode.
-----------------------------------------------------------------------------------------------------------------------------------------------------
Presentation
Acute Pericarditis
§ Chest pain ® sharp, dull, burning, pleuritic, better leaning forward and sitting up, radiation to trapezius ridge
§ Low grade fever
§ Breathlessness
§ Cough
§ Tachycardia, tachypnoea
§ Auscultation ® pericardial friction rub (scratchy, squeaking sound)
§ Features of cardiac tamponade ® muffled heart sounds, distended JVP, pulsus paradoxus (fall in BP >10 mmHg during
inspiration), hypotension.
Chronic Pericarditis
Patients characteristically present with features of right heart failure.
§ SOB
§ Leg swelling (peripheral oedema)
§ Abdominal swelling (ascites)
§ Exercise intolerance
§ Raised JVP
§ Hepatomegaly.
-----------------------------------------------------------------------------------------------------------------------------------------------------
Pathophysiology
The serous pericardium = double layered membrane surrounding the heart
§ Pericardium ® tough, outer fibrous layer + inner, serous layer, 1-2 mm thick
o Serous pericardium comprised of 2 membranes
§ Parietal pericardium ® internal surface of the fibrous pericardium
§ Visceral pericardium ® inner membrane (epicardium) covering the heart and great vessels
§ Pericardial space ® contains serous fluid (20-50 ml)
§ The pericardium has 3 main functions
o Mechanical ® limits cardiac dilation, maintains ventricular compliance, aids atrial filling
o Barrier ® reduces external friction, barrier roles
o Anatomical ® fixes heart in place
§ In most cases of acute pericarditis, the pericardial sac is acutely inflamed with infiltration of immune cells secondary to
acute infection (transient viral infection) or as manifestation of systemic disease
§ There are many possible causes of acute pericarditis
o Idiopathic ® possibly undiagnosed viral infection
o Viral (1-10%) ® short-lived lasting 1-3 weeks, most common is coxsackievirus B
§ Other viruses include: influenza, echovirus, adenovirus, enterovirus
o Bacterial (1-8%) ® mostly due to haematogenous spread, extension from pulmonary infection or as
complication of endocarditis or trauma
o TB (4%) ® investigate in high prevalence areas or high risk patients, high risk of chronic pericarditis and
constrictive complication
o Systemic disease ® e.g. RA
o Other ® drugs, radiotherapy, trauma
o Uraemia
o Dressler’s syndrome ® autoimmune form occurring 2-3 weeks post-MI
§ Chronic pericarditis is more likely in patients with bacterial or tuberculosis pericarditis
§ The main consequence of more chronic inflammation of pericardium is development of constrictive pericarditis
o Development of constrictive pericarditis has 3 clinical phenotypes
§ Transient constriction ® reversible with resolution spontaneously or medical therapy
§ Effusion-constriction ® constrictive pericarditis with evidence of a pericardial effusion (features of
constriction persist even after removal of pericardial fluid)
§ Chronic constriction ® constriction 3-6 months duration
Acute pericarditis = inflammation of the heart sac, aka pericardium, with acute-onset symptoms and ECG features
Chronic pericarditis = >3 months of inflammation involving the pericardium, usually following an acute episode.
-----------------------------------------------------------------------------------------------------------------------------------------------------
Presentation
Acute Pericarditis
§ Chest pain ® sharp, dull, burning, pleuritic, better leaning forward and sitting up, radiation to trapezius ridge
§ Low grade fever
§ Breathlessness
§ Cough
§ Tachycardia, tachypnoea
§ Auscultation ® pericardial friction rub (scratchy, squeaking sound)
§ Features of cardiac tamponade ® muffled heart sounds, distended JVP, pulsus paradoxus (fall in BP >10 mmHg during
inspiration), hypotension.
Chronic Pericarditis
Patients characteristically present with features of right heart failure.
§ SOB
§ Leg swelling (peripheral oedema)
§ Abdominal swelling (ascites)
§ Exercise intolerance
§ Raised JVP
§ Hepatomegaly.
-----------------------------------------------------------------------------------------------------------------------------------------------------
Pathophysiology
The serous pericardium = double layered membrane surrounding the heart
§ Pericardium ® tough, outer fibrous layer + inner, serous layer, 1-2 mm thick
o Serous pericardium comprised of 2 membranes
§ Parietal pericardium ® internal surface of the fibrous pericardium
§ Visceral pericardium ® inner membrane (epicardium) covering the heart and great vessels
§ Pericardial space ® contains serous fluid (20-50 ml)
§ The pericardium has 3 main functions
o Mechanical ® limits cardiac dilation, maintains ventricular compliance, aids atrial filling
o Barrier ® reduces external friction, barrier roles
o Anatomical ® fixes heart in place
§ In most cases of acute pericarditis, the pericardial sac is acutely inflamed with infiltration of immune cells secondary to
acute infection (transient viral infection) or as manifestation of systemic disease
§ There are many possible causes of acute pericarditis
o Idiopathic ® possibly undiagnosed viral infection
o Viral (1-10%) ® short-lived lasting 1-3 weeks, most common is coxsackievirus B
§ Other viruses include: influenza, echovirus, adenovirus, enterovirus
o Bacterial (1-8%) ® mostly due to haematogenous spread, extension from pulmonary infection or as
complication of endocarditis or trauma
o TB (4%) ® investigate in high prevalence areas or high risk patients, high risk of chronic pericarditis and
constrictive complication
o Systemic disease ® e.g. RA
o Other ® drugs, radiotherapy, trauma
o Uraemia
o Dressler’s syndrome ® autoimmune form occurring 2-3 weeks post-MI
§ Chronic pericarditis is more likely in patients with bacterial or tuberculosis pericarditis
§ The main consequence of more chronic inflammation of pericardium is development of constrictive pericarditis
o Development of constrictive pericarditis has 3 clinical phenotypes
§ Transient constriction ® reversible with resolution spontaneously or medical therapy
§ Effusion-constriction ® constrictive pericarditis with evidence of a pericardial effusion (features of
constriction persist even after removal of pericardial fluid)
§ Chronic constriction ® constriction 3-6 months duration
