History

Fact Explanation
Shortness of breath [1] Chronic (>3months) pericarditis [2] leads to scarred, thickened, and frequently calcified pericardium which impairs cardiac filling, limiting the total cardiac volume.Patient may feel shortness of breath due to impaired cardiac out put [1]
Fatigue [1] Patient may feel fatigue due to impaired cardiac out put caused by scarred pericardium [1]
Palpitations [4] Related to the degree of cardiac compression and pericardial inflammation [2]
Chest pain [2] Not so severe as in acute pericarditis. Pain occurs due to cardiac compression and pericardial inflammation [2]
Poor exercise tolerance [3] Due to impaired cardiac out put caused by cardiac compression [3]
Depressions over the chest [1] Due to sunken intercostal spaces caused by cardiac compression [1]
Past history of tuberculosis [2] Tuberculosis can cause pericardial scar formation (tuberculous pericarditis) [5]
Past history of cardiac surgery [3] Can cause scar formation in the paricardium [1]
Past history of rheumatic heart disease [1] Can cause scar formation in pericardium [1]
Systemic diseases eg: systemic lupus erythematosus [1] Can give rise to scar formation in pericardium [1]
History of malignancy of chest or malignant infiltrate of chest / irradiation to chest [1] Can cause scar formation in pericardium [1]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  3. KHANDAKER MH, ESPINOSA RE, NISHIMURA RA, SINAK LJ, HAYES SN, MELDUNI RM, OH JK. Pericardial Disease: Diagnosis and Management Mayo Clin Proc [online] 2010 Jun, 85(6):572-593 [viewed 06 July 2014] Available from: doi:10.4065/mcp.2010.0046
  4. Corrigendum: Primary Purulent Pericarditis with Cardiac Tamponade due to Oropharyngeal Polymicrobial Infection: A Case Report and Literature Review. Korean J Thorac Cardiovasc Surg [online] 2014 Jun, 47(3):325 [viewed 30 September 2014] Available from: doi:10.5090/kjtcs.2014.47.3.325
  5. PANDIE S, PETER JG, KERBELKER ZS, MELDAU R, THERON G, GOVENDER U, NTSEKHE M, DHEDA K, MAYOSI BM. Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous pericarditis compared to adenosine deaminase and unstimulated interferon-? in a high burden setting: a prospective study BMC Med [online] :101 [viewed 30 September 2014] Available from: doi:10.1186/1741-7015-12-101

Examination

Fact Explanation
Dyspnoea [1] Pericardial constriction occurs when a scarred, thickened, and frequently calcified pericardium impairs cardiac filling, limiting the total cardiac volume.Patient may be dyspneic due to impaired cardiac output [1]
Rapid, feeble pulse /Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration ) [1] Due to reduced cardiac out put caused by cardiac compression [1]
Systolic tug [2] Occur with each pulsation and may be seen near the sternum, between the seventh and eighth interspace [2]
Indrawn intercostal spaces posteriorly (Broadbent's sign) [1] On examining the back of the patient a visible retraction of the chest will be observed between the eleventh and twelfth ribs, during each systole.Occurs due to adhesions [1]
Friedreich's sign [1] Exaggerated drop in diastolic central venous pressure seen particularly with a stiff calcified pericardium and manifested as abrupt collapse of the neck veins or marked descent of the central venous pressure waveform [1]
Jugular venous distension [2] Due to increased systemic venous pressure [2]
Ascites, peripheral oedema [2] Due to increased systemic venous pressure [2]
Scar marks due to cardiac surgeries [3] Can cause scar formation in pericardium due to cardiac surgeries [1]
Wasted apparance [3] Due to tuberculosis which can give rise to tuberculous pericarditis giving rise to pericardial adhesion [3]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  3. KHANDAKER MH, ESPINOSA RE, NISHIMURA RA, SINAK LJ, HAYES SN, MELDUNI RM, OH JK. Pericardial Disease: Diagnosis and Management Mayo Clin Proc [online] 2010 Jun, 85(6):572-593 [viewed 06 July 2014] Available from: doi:10.4065/mcp.2010.0046

Differential Diagnoses

Fact Explanation
Pericarditis with effusion [1] Convexity or bulging of the intercostal spaces rather than a depression as in adhesive pericarditis. The diastolic shock or rebound is absent where there is effusion [1]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram (ECG) [1] Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity. Early stage II: ST junctions return to the baseline, PR deviated. Late stage II: T waves progressively flatten and invert Stage III: generalised T wave inversions Stage IV: ECG returns to pre pericarditis state [1]
Chest x ray [3] Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml [1] Also to identify other pathological conditions eg:tumours [2]
Echocardiogram [3] To assess the ejection fraction [1] Thickened pericardium (>2 mm) that can be imaged by echocardiography [2]
CT / MRI chest [2] Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours [2]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  3. EKIM M, EKIM H. Diagnostic value of the biochemical tests in patients with purulent pericarditis Pak J Med Sci [online] 2014, 30(4):845-849 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121710

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] To assess general medical condition of the patient. eg: hemoglobin levels Also there may be changes in the full blood count in certain diseases eg: changes in platelet counts in systemic lupus erythematosus [1]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002

Investigations - Followup

Fact Explanation
Electrocarigram [1] Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity. Early stage II: ST junctions return to the baseline, PR deviated. Late stage II: T waves progressively flatten and invert Stage III: generalised T wave inversions Stage IV: ECG returns to pre pericarditis state [1]
Echocardiogram [1] To assess the ejection fraction [1] Thickened pericardium (>2 mm) that can be imaged by echocardiography [2]
Chest x ray [1] Heart appears normal in pericarditis.Cardiomegaly appears if there is an effusion exceeding 250 ml [1] Also to identify other pathological conditions eg:tumours [2]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514

Investigations - Screening/Staging

Fact Explanation
Elaectrocardiogram [1] Stage I: anterior and inferior concave ST segment elevation. PR segment deviations opposite to P polarity. Early stage II: ST junctions return to the baseline, PR deviated. Late stage II: T waves progressively flatten and invert Stage III: generalised T wave inversions Stage IV: ECG returns to pre pericarditis state [1]
Chest x ray [1] Tuberculous changes , other pathologies (tumours) can be identified [1]
CT / MRI chest [2] Demonstrate adhesion of the pericardium.Also to identify other pathological conditions eg:tumours [2]
Echocardiogram [1] To assess the ejection fraction [1] Thickened pericardium (>2 mm) that can be imaged by echocardiography [2]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 06 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514

Management - General Measures

Fact Explanation
Non steroidal anti inflammatory drugs (NSAIDs) [1] For pain relief. [1]
Colchicine [1] If the pericardial pain and inflammation do not respond to NSAIDs [1]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514

Management - Specific Treatments

Fact Explanation
Pericardiocentesis [2] For diagnostic purposes. (tissue analysis) [1]
Balloon pericardiotomy or pericardiectomy [1] Should be considered for frequent and symptomatic recurrences [1]
Treat the specific cause eg:Treatment for tuberculous pericarditis [1] Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied [1]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 06 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. YAVUZ S, KASAP M, AKPINAR G, OZBUDAK E, URAL D, BERKI T. Analysis of pericardial effusion from idiopathic pericarditis patients by two-dimensional gel electrophoresis. Biomed Res Int [online] 2014:942718 [viewed 30 September 2014] Available from: doi:10.1155/2014/942718