Pericarditis

Pericarditis

The patient who is complaining of retrosternal chest pain which is sharp and relieved by sitting up or leaning forward, gets worse when lying down, breathing, coughing and radiates to the both arms will tell us that it might be acute pericarditis. In this case physical examination will show decrease in apex pulse, by percussion the heart would be slightly enlarged and a slight friction rub by auscultation on lower left sternal border. And then we will do diagnostic tests including ECG, echocardiography, chest X-ray, and also some lab tests. ECG might show ST elevation, and also there might be PR depression. To differentiate from myocardial infarction there won’t be any pathologic q wave. We will measure pericardial fluid amount and quality by echocardiography. By doing chest x-ray we can see the pericardial fluid too. Since it is an inflammation process there will be increased erythrocyte sedimentation rate, lymphocyte. In some cases there might be slight change in creatinine kinase.
Main complication of acute pericarditis is cardiac tamponade. In case of tamponade clinical symptoms may include coughing, dyspnea, hoarseness. Physical examination will reveal classical tamponade signs which is known as Beck’s triad. Hypotension occurs because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid inside the pericardium. Other signs of tamponade include pulsus paradoxus and ST segment changes on the electrocardiogram which may also show low voltage QRS complexes as well as general signs & symptoms of shock (such as tachycardia, breathlessness and decreasing level of consciousness). Also can be diagnosed radiographically by echocardiography. In echocardiography we can see fluid accumulation and chest X-ray will show a large globular heart.
If we don’t treat or diagnose acute pericarditis in time it will develop into constrictive pericarditis or chronic pericarditis. If the patient has chronic pericarditis he or she will be tired, have dyspnea and peripheral edema which are not so specific. Physical examination will reveal increased JVP, kussmau’sl sign, in very rare cases there will be pulsus paradoxus, pericardial knock in around 50% cases and hepatomegaly. Imaging will demonstrate a thickened pericardium and chest X-Ray will demonstrate pericardial calcification pleural effusions are common findings. In echocardiography pericarditis will be thickened, left ventricular enlargement and in some cases you can see pericardial fluid. In severe cases lab findings will reveal damage of other organs.
Treatment will include NSAID’s and if it’s from bacterial causes antibiotics, and if from virus antiviral drugs will be used. In recurrent cases, especially in immunologically-mediated causes, corticosteroids are often very effective. Non pharmacologic treatment include pericardiocentesis, a procedure where a thin needle is inserted into the pericardial sac, may be considered if there is too much fluid, or to diagnose underlying cause. Besides pericardiocentesis there is also pericardiectomy which is removal of part of the pericardium.