Pericarditis

Features

•    Pleuritic, sharp chest pain

o    Worse when lying flat, better sitting forward

•    May radiate to trapezius ridge (phrenic nerve involvement)

•    Pericardial friction rub (high-pitched, superficial sound)

ECG changes

•    Widespread concave ST elevation (all leads except aVR, V1)

•    PR depression (specific for pericarditis)

Common causes

•    Viral (coxsackie, echovirus)

•    Post-MI (Dressler's syndrome: fever, pericarditis, pleural effusion ~2 weeks after MI)

•    Uraemia

•    Connective tissue diseases (e.g., SLE)

Treatment

•    NSAIDs (e.g., ibuprofen)

•    Colchicine (reduces recurrence)

•    Steroids only if refractory or autoimmune cause

Pericardial Effusion

Features

•    Dyspnoea, "globular" cardiac silhouette on CXR

•    Diminished heart sounds

•    Electrical alternans (beat-to-beat variation in QRS amplitude)

Causes

•    Any cause of pericarditis

•    Hypothyroidism ("myxoedema heart")

•    Malignancy (lung, breast, lymphoma)

Cardiac Tamponade

Features

•    Beck’s triad:

o    Hypotension (low cardiac output)

o    Raised JVP (venous congestion)

o    Muffled heart sounds

•    Pulsus paradoxus

o    Drop in systolic BP >10 mmHg on inspiration

•    Tachycardia, dyspnoea, oliguria

Diagnosis

•    Echo: diastolic collapse of RA/RV

•    ECG: low voltage, electrical alternans

Management

•    Urgent pericardiocentesis

Constrictive Pericarditis

Pathophysiology

•    Thickened, calcified pericardium → diastolic dysfunction → equalisation of diastolic pressures

Features

•    Similar to right heart failure (RHF): ascites, hepatomegaly, peripheral oedema

•    Kussmaul’s sign: JVP rises on inspiration

•    Pericardial knock (early diastolic sound)

Causes

•    TB (common worldwide)

•    Post-cardiac surgery, radiation, idiopathic

Imaging

•    CT/MRI: pericardial thickening, calcification

Treatment

•    Pericardiectomy (definitive)

Extra Revision Pearls

•    Pericarditis clue → PR depression, concave ST elevation, pain improves sitting up

•    Dressler’s clue → post-MI pericarditis, fever, pleuritis

•    Tamponade clue → hypotension + high JVP + muffled heart sounds + pulsus paradoxus

•    Electrical alternans clue → large effusion or tamponade

•    Constrictive clue → RHF + Kussmaul’s + pericardial knock