Cardiovascular

Pericardial Disease

Pericardial disease ranges from inflammation and effusion to tamponade and chronic constriction; the clinical priority is to identify the dominant syndrome, assess haemodynamic danger and cause, and match anti-inflammatory, drainage or surgical treatment to that syndrome.

In a nutshell

Pericardial disease presents as inflammation, effusion or tamponade, myocardial overlap, or chronic constriction. Use echocardiography to assess effusion and haemodynamic effect, treat tamponade urgently by drainage, treat uncomplicated pericarditis with aspirin or an NSAID plus colchicine, and refer constrictive or refractory disease to a specialist centre.

Classic presentation

Sharp positional chest pain with a friction rub in pericarditis; shock with raised JVP in tamponade; or chronic right-sided congestion, Kussmaul sign and a pericardial knock in constriction.

Key points

The main syndromes are pericarditis, effusion, tamponade, myopericardial involvement and constriction; they can overlap or evolve.
Effusion size alone does not define danger: a rapid small effusion can tamponade, while a slow large one may be tolerated.
Echocardiography is the key first cardiac test; cardiac MRI and CT answer selected myocardial, pericardial, cause and constriction questions.
Uncomplicated pericarditis needs anti-inflammatory treatment plus colchicine; tamponade needs urgent drainage; constriction needs specialist assessment.
Troponin elevation, ventricular dysfunction, arrhythmia or syncope indicates myocardial overlap and a higher-risk pathway.
Purulent, traumatic, bleeding, malignant or dissection-related disease needs cause-specific specialist treatment.

First-line investigation

Haemodynamic assessment, ECG, troponin and inflammatory markers with transthoracic echocardiography; select CT or cardiac MRI for cause or constriction.

Management

Identify the syndrome and emergency

Assess for pericarditis, effusion, tamponade, myocardial overlap and constriction while excluding ACS, PE and dissection; treat shock first.^1,2,3

Image and treat inflammation

Use echocardiography as the key first cardiac test and treat uncomplicated pericarditis with aspirin or an NSAID plus colchicine and activity restriction.^1,4

Drain and treat the cause

Drain tamponade or a clinically indicated effusion urgently, choose surgery for selected causes, send fluid for analysis and treat infection, malignancy, renal, autoimmune or post-procedural disease.^1,5,3

Refer constriction and overlap

Refer recurrent, refractory, myopericardial or constrictive disease for specialist imaging, multidisciplinary treatment and possible pericardiectomy.¹

Monitor the trajectory

Review symptoms, ECG, inflammatory activity, ventricular function, effusion and venous congestion, and give explicit safety-netting for recurrent tamponade or infection.^1,2,6

Exam traps

A normal chest radiograph does not exclude an effusion or tamponade.
A raised troponin is not automatically uncomplicated pericarditis; consider myopericardial disease and specialist restriction.
Kussmaul sign and a pericardial knock suggest constriction, while pulsus paradoxus and shock suggest tamponade.
Drainage route depends on cause and anatomy: purulent, traumatic, clot-filled or dissection-related effusions may need surgery.
Do not delay treatment of unstable tamponade while waiting for CT, MRI or a complete cause panel.

Illustrations

Pericardial effusion on CTAxial contrast-enhanced CT showing a large circumferential pericardial effusion surrounding the heart, with labels distinguishing fluid from the myocardium and pleural space.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.