Doctors Revision

Cardiovascular System

Pericarditis

Inflammation of the pericardium, the sac surrounding the heart. Can be acute, subacute, or chronic, and may occur with or without pericardial effusion.

Also known as: Inflamed Heart Sac

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Referral and warning signs

When to refer

Hospital admission (H/RR) usually recommended for first episode to confirm diagnosis, rule out MI, monitor for tamponade. Urgent referral/consultation needed if: Cardiac tamponade suspected. Large effusion. High-risk features (fever >38C, subacute onset, immunosuppression, trauma, anticoagulant use, elevated troponin, failure to respond to NSAIDs within 1 week). Suspected purulent, TB, or neoplastic cause.

Red flags

  • Signs of cardiac tamponade (hypotension, raised JVP, muffled sounds, pulsus paradoxus)
  • Large pericardial effusion on echocardiogram
  • High fever, signs of sepsis (suggests purulent pericarditis)
  • Failure to improve with NSAIDs/Colchicine
  • Elevated troponin (suggests myopericarditis or MI)

Signs and symptoms

  • Acute Pericarditis: Sharp, retrosternal or left-sided chest pain, often pleuritic (worse with deep breath, coughing). Pain may radiate to trapezius ridge (pathognomonic), neck, or shoulders. Pain often relieved by sitting up and leaning forward, worse when lying flat.
  • Pericardial friction rub: Scratchy, grating sound heard on auscultation (best heard with diaphragm, patient leaning forward, end-expiration). May be transient or triphasic.
  • Fever, malaise, myalgia (if infectious/inflammatory cause).
  • Dyspnoea (may be due to pain or associated effusion/tamponade).
  • Pericardial Effusion (Fluid accumulation): May be asymptomatic if small/slowly accumulating. Larger effusions can cause dyspnoea, cough, distant/muffled heart sounds.
  • Cardiac Tamponade (Compression due to rapid/large effusion): Beck's triad (hypotension, raised JVP, muffled heart sounds), pulsus paradoxus (inspiratory drop in SBP >10 mmHg), tachycardia, dyspnoea, restlessness, shock.

Risk factors

  • Idiopathic (presumed viral) - most common
  • Viral infections (Coxsackie, influenza, HIV, etc.)
  • Bacterial infections (Tuberculosis, Pneumococcus, Staphylococcus - purulent pericarditis)
  • Fungal infections (Histoplasmosis)
  • Uraemia (severe kidney failure)
  • Post-myocardial infarction (early or late - Dressler's syndrome)
  • Trauma (blunt or penetrating)
  • Cardiac surgery
  • Radiation therapy to chest
  • Neoplasms (primary or metastatic)
  • Autoimmune/Connective tissue diseases (SLE, Rheumatoid Arthritis)
  • Hypothyroidism
  • Drug-induced

Diagnosis

Clinical assessment

Diagnosis suspected based on characteristic chest pain (retrosternal/pleuritic, relieved by leaning forward) and pericardial friction rub. Assess for signs of effusion/tamponade (JVP, heart sounds, pulsus paradoxus, BP). Differential diagnosis: Myocardial infarction, Pulmonary embolism, Pneumonia/Pleurisy, GERD, Costochondritis, Aortic dissection.

Investigations

  • ECG: Key investigation. Shows characteristic diffuse, concave-up ST segment elevation and PR segment depression (Stage 1). Evolves over time (ST normalizes, T waves invert - Stage 3). May show low voltage QRS or electrical alternans if large effusion.
  • Echocardiogram: Essential. Confirms pericardial effusion, assesses its size and haemodynamic significance (signs of tamponade - diastolic chamber collapse, respiratory variation in flows). Can show thickened pericardium in constrictive pericarditis.
  • Chest X-ray: Often normal in acute pericarditis without effusion. May show enlarged cardiac silhouette ('water bottle heart') if large effusion (>250ml).
  • Blood tests: CBC (leucocytosis), ESR/CRP (elevated inflammatory markers), Cardiac biomarkers (Troponin may be slightly elevated due to epicardial inflammation, but usually much less than in MI), Renal function (uraemia), TSH. Consider blood cultures if bacterial cause suspected.
  • Pericardiocentesis (Fluid analysis): If tamponade present or if bacterial/malignant/TB cause suspected. Analyse fluid for cell count, protein, glucose, Gram stain, culture (bacterial, fungal, AFB), cytology.

Diagnostic criteria

Diagnosis typically requires at least 2 of 4 criteria: 1) Typical pericarditic chest pain, 2) Pericardial friction rub, 3) Characteristic ECG changes, 4) New or worsening pericardial effusion.

Management

Non-pharmacological management

  • Rest.
  • Identify and treat underlying cause (e.g., antibiotics for bacterial, anti-TB drugs for TB, dialysis for uraemia).
  • Pericardiocentesis: Therapeutic drainage for cardiac tamponade. Diagnostic aspiration for suspected purulent, TB, or malignant effusion.
  • Pericardial window/Pericardiectomy: Surgical procedures for recurrent effusions or constrictive pericarditis (specialist).

Pharmacological treatment

  • Acute Idiopathic/Viral Pericarditis:
  • - NSAIDs: High-dose NSAID is first-line. E.g., Ibuprofen 600-800 mg TID OR Aspirin 650-1000mg TID for 1-2 weeks, then taper slowly.
  • - Colchicine: 0.5-0.6 mg BID (or OD if <70kg) for 3 months. Reduces recurrence rates when added to NSAIDs.
  • - Gastroprotection (PPI or H2 blocker) with NSAID therapy.
  • - Corticosteroids (e.g., Prednisolone): Generally avoided for initial episode (may increase recurrence). Reserved for refractory cases, autoimmune causes, or contraindications to NSAIDs/Colchicine (specialist use).
  • Specific Causes:
  • - Bacterial (Purulent): Requires urgent drainage + specific IV antibiotics based on likely pathogens/culture results.
  • - Tuberculous: Requires standard multi-drug anti-TB therapy (see TB001) +/- corticosteroids.
  • - Uraemic: Intensify dialysis. NSAIDs often ineffective.
  • - Post-MI/Dressler's: Aspirin or Colchicine preferred over other NSAIDs. Avoid steroids initially.

Monitoring

  • Monitor symptoms (pain resolution).
  • Monitor inflammatory markers (CRP/ESR) - should normalize.
  • Monitor for signs of effusion/tamponade (JVP, heart sounds, BP, pulsus paradoxus).
  • Follow-up echocardiogram if effusion present.
  • Monitor for side effects of medications (NSAID gastritis, Colchicine diarrhoea).

Complications

  • Pericardial effusion
  • Cardiac tamponade (life-threatening)
  • Recurrent pericarditis
  • Constrictive pericarditis (chronic thickening/scarring impairing diastolic filling)

Prevention

  • Treat underlying conditions promptly.
  • Colchicine reduces recurrence risk after first episode of viral/idiopathic pericarditis.

Patient education

  • Explain the diagnosis and likely (often viral/idiopathic) cause.
  • Reassure that most cases resolve without long-term issues.
  • Explain medication regimen (NSAID + Colchicine) and importance of completing course/tapering.
  • Advise rest and activity restriction during acute phase.
  • Educate on symptoms of recurrence or complications (worsening pain, severe dyspnoea, dizziness) requiring return.
  • Discuss potential side effects of medications.

Uganda-specific notes

TB pericarditis is a significant consideration, especially in PLHIV. Access to echocardiography is essential for diagnosis and assessment of effusion/tamponade but may be limited. Empirical treatment for viral/idiopathic cause with NSAIDs (+/- Colchicine if available) is common.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 4, Section 4.1.8

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