Understanding and Managing Pericarditis: A Guide for Junior Doctors

Welcome, junior doctors! Today, we're delving into the intricacies of pericarditis—an inflammation of the pericardium, the fluid-filled sac surrounding the heart. This condition can range from mild to life-threatening, and as budding emergency medicine professionals, it's crucial to master the art of diagnosing and managing pericarditis effectively. Let’s break down the essentials: history taking, physical examination, investigations, and management.

History Taking: The Foundation of Diagnosis

When a patient presents with chest pain, pericarditis should be on your differential. Here are key questions to ask:

1. Nature of Pain:

   • Character: Describe the chest pain. Is it sharp or stabbing?

   • Location: Where exactly is the pain? Does it radiate to the neck, shoulders, or back?

   • Timing: When did the pain start? Is it constant or intermittent?

2. Aggravating and Relieving Factors:

   • Position: Does the pain worsen when lying down and improve when sitting up or leaning forward?

   • Breathing: Is the pain exacerbated by deep breaths or coughing?

3. Associated Symptoms:

   • Fever: Have you had a fever or chills?

   • Dyspnea: Are you experiencing shortness of breath?

   • Other Symptoms: Any recent infections or illnesses, particularly respiratory or gastrointestinal?

4. Medical and Surgical History:

   • Recent Illnesses: Any recent viral infections or respiratory illnesses?

   • Trauma: Any recent chest trauma or surgeries?

   • Medications: Are you on any medications, especially anticoagulants or immunosuppressants?

Physical Examination: Clues from the Body

A thorough physical examination can provide critical clues:

1. Vital Signs: Check for fever, tachycardia, and hypotension.

2. Inspection and Palpation:

   • JVP: Elevated jugular venous pressure could indicate cardiac tamponade.

   • Pulsus Paradoxus: A decrease in systolic blood pressure by more than 10 mm Hg during inspiration may suggest tamponade.

3. Auscultation:

   • Pericardial Friction Rub: A high-pitched, scratchy sound best heard with the diaphragm of the stethoscope at the left sternal border, which may be intermittent.

Investigations: Unveiling the Diagnosis

To confirm your suspicion and rule out other conditions, here are the investigations to consider:

1. Electrocardiogram (ECG):

   • ST Elevation: Diffuse, concave ST-segment elevation across multiple leads.

   • PR Depression: Particularly in the precordial leads.

   • T-wave Inversion: May occur later in the disease process.

2. Echocardiography:

   • Pericardial Effusion: Look for any fluid accumulation around the heart.

   • Tamponade Signs: Right atrial or right ventricular diastolic collapse.

3. Blood Tests:

   • Inflammatory Markers: Elevated ESR and CRP.

   • Cardiac Enzymes: Troponins may be mildly elevated but less so than in myocardial infarction.

4. Chest X-ray:

   • Cardiomegaly: Suggestive of pericardial effusion, though not always present.

5. Advanced Imaging:

   • Cardiac MRI or CT: For detailed evaluation if diagnosis remains unclear.

Management: Tailoring the Treatment

Management of pericarditis involves addressing the underlying cause and providing symptomatic relief:

1. First-Line Treatment:

   • NSAIDs: Ibuprofen or aspirin to reduce inflammation and pain.

   • Colchicine: Reduces recurrence rates; used in combination with NSAIDs.

2. Adjunctive Treatment:

   • Corticosteroids: Reserved for refractory cases or when NSAIDs/colchicine are contraindicated.

3. Specific Cases:

   • Infectious Pericarditis: Appropriate antibiotics if bacterial.

   • Autoimmune Pericarditis: Consider immunosuppressive therapy.

   • Uremic Pericarditis: Dialysis optimization.

4. Monitoring and Follow-up:

   • Echocardiographic Monitoring: For effusion resolution.

   • Symptom Monitoring: Ensure resolution of chest pain and other symptoms.

5. Complications:

   • Cardiac Tamponade: Emergent pericardiocentesis if hemodynamically unstable.

   • Constrictive Pericarditis: Consider surgical intervention if chronic.

Conclusion

Mastering the management of pericarditis begins with a solid foundation in history taking and physical examination. By integrating clinical findings with appropriate investigations, you can tailor an effective management plan. Always remember, timely intervention can significantly impact patient outcomes.

Stay curious, stay vigilant, and keep learning! As you continue your journey in emergency medicine, each patient encounter will sharpen your skills and expand your expertise.

Happy practicing!