284.1 🎓 醫孞生版

284.1.0.1 📌 䞀頁重點

284.1.0.1.1 Anatomy
284.1.0.1.1.1 Pericardium
  • Visceral (epicardium): attached to heart
  • Parietal: outer layer
  • Pericardial space: 15-50 mL serous fluid
  • Functions: lubrication, isolation, prevents over-distension
284.1.0.1.2 Acute Pericarditis
284.1.0.1.2.1 Definition
  • Inflammation of pericardium ≀ 6 weeks
  • Diagnosis: ≥ 2 of 4 criteria:
    1. Pericarditic chest pain
    2. Pericardial friction rub
    3. New ECG changes (diffuse ST↑ + PR↓)
    4. Pericardial effusion (new or worsening)
284.1.0.1.2.2 Etiologies
  • Viral / idiopathic (~ 80%): coxsackievirus, echovirus, adenovirus, EBV, CMV, influenza, COVID-19
  • Bacterial: Staph, Strep, Gram-negatives (purulent, severe)
  • TB: especially in endemic areas; constrictive risk
  • Fungal (immunocompromised)
  • Autoimmune: SLE, RA, scleroderma, vasculitis
  • Uremic (BUN > 60)
  • Post-MI:
    • Early (1-3 d, peri-infarct) — friction rub from epicardial irritation
    • Dressler syndrome (2-10 wk) — autoimmune
  • Post-cardiac surgery (post-pericardiotomy syndrome)
  • Radiation
  • Drugs: hydralazine, procainamide, isoniazid, phenytoin (drug-induced lupus); minoxidil
  • Trauma
  • Malignancy: lung, breast, lymphoma, melanoma
  • Aortic dissection (don’t miss!)
284.1.0.1.2.3 Clinical Features
  • Chest pain:
    • Sharp, pleuritic
    • Substernal, radiation to trapezius
    • Worse supine, better sitting forward
    • Worse with inspiration, swallowing
  • Friction rub: superficial scratching; 3 components (ventricular systole, early diastolic filling, atrial systole); transient
  • Fever, malaise
  • Tachycardia (HR > 100)
  • Dyspnea if effusion
284.1.0.1.2.4 ECG (4 Stages)
  • Stage I (hours-days): Diffuse ST↑ + PR↓; PR↑ in aVR
  • Stage II (days-weeks): ST normalizes; T flattens
  • Stage III: T inversion (diffuse)
  • Stage IV: ECG returns to normal
  • Distinguish from STEMI: diffuse vs localized; no reciprocal changes; PR↓ specific
284.1.0.1.2.5 Investigations
  • CBC, ESR, CRP (CRP excellent for monitoring)
  • Troponin (often elevated if myocarditis component → myopericarditis)
  • BUN/Cr (uremic)
  • ANA, RF (autoimmune)
  • TB testing if at risk
  • Viral serologies rarely useful
  • Echocardiogram: detect effusion, tamponade, assess function
  • CMR: T2 hyperintensity (edema), LGE pericardial enhancement
284.1.0.1.2.6 Treatment of Acute Pericarditis
  • NSAID + colchicine = standard
    • NSAID:
      • Ibuprofen 600 mg TID × 1-2 weeks → taper
      • ASA 750-1000 mg TID × 1-2 weeks (preferred post-MI)
      • Indomethacin 50 TID (less preferred)
    • Colchicine: 0.5 mg BID (or 0.5 mg daily if < 70 kg) × 3 months
      • CORP, ICAP trials — reduces recurrence by 50%
  • Activity restriction: avoid strenuous exercise until symptoms resolve and inflammation normalizes
  • Steroids: only for refractory, autoimmune, contraindication to NSAID; AVOID first-line (↑ recurrence)
  • PPI for GI protection
  • Treat underlying cause (TB, autoimmune, uremic, etc.)
284.1.0.1.2.7 Recurrent Pericarditis
  • 15-30% have recurrence
  • 5-10% have chronic recurrent
  • Treatment:
    1. NSAID + colchicine for 6 months
    2. Steroids if refractory (prednisone 0.2-0.5 mg/kg)
    3. Rilonacept (IL-1 trap) — FDA 2021 — RHAPSODY trial 2020 ↓ recurrence 96%
    4. Anakinra (IL-1 receptor antagonist) — AIRTRIP trial
    5. Azathioprine, IVIG — refractory autoimmune
    6. Pericardiectomy — last resort for incessant disease
284.1.0.1.3 Pericardial Effusion
284.1.0.1.3.1 Classification
  • Size (echo): trivial (< 5 mm), small (5-10), moderate (10-20), large (> 20)
  • Time course: acute (rapid, low volume can tamponade) vs chronic
  • Type: serous, exudative, hemorrhagic, chylous, purulent
284.1.0.1.3.2 Etiology (Same as Acute Pericarditis +)
  • Trauma, surgery
  • LV rupture (post-MI)
  • Aortic dissection
  • HF (transudative)
  • Hypothyroidism
  • Renal failure
  • Malignancy (large, hemorrhagic, recurrent)
  • Iatrogenic (post-PCI, post-pacemaker)
284.1.0.1.3.3 Clinical
  • Often asymptomatic if small/chronic
  • Dyspnea, fatigue, chest discomfort
  • Lower extremity edema, hepatomegaly if RV impaired
  • Bezold sign (hoarseness from LRN compression)
  • Ewart sign (dullness L scapular tip — atelectasis from large effusion)
284.1.0.1.3.4 Diagnosis
  • Echocardiogram (TTE) — best
    • 2D effusion quantification
    • Doppler — hemodynamic effects, tamponade physiology
  • ECG: low voltage, electrical alternans (varying QRS amplitude — large effusion)
  • CXR: enlarged “water-bottle” cardiac silhouette
  • CT / CMR: characterize fluid, masses, pericardial thickening
284.1.0.1.3.5 Pericardiocentesis
  • Indications:
    • Tamponade (emergency)
    • Diagnostic for unclear etiology (especially malignancy, infection)
    • Large symptomatic effusion
  • Subxiphoid approach common
  • Echo-guided (or fluoroscopy)
  • Send fluid for: cell count, gram stain, culture, AFB, cytology, ADA, cholesterol/TG (chylous), LDH, glucose, protein
284.1.0.1.3.6 Pericardial Window (Surgical Drainage)
  • Subxiphoid window or thoracoscopic
  • For recurrent effusion, malignancy
  • Allows pericardial biopsy
284.1.0.1.4 Cardiac Tamponade
284.1.0.1.4.1 Pathophysiology
  • Rapid or large effusion → ↑ intrapericardial pressure
  • Diastolic dysfunction: ventricular filling impaired
  • Equalization of diastolic pressures (RA = RV = LA = LV = pericardial)
  • ↓ cardiac output → hypotension, shock
  • Tachycardia + compensatory peripheral vasoconstriction
284.1.0.1.4.2 Beck Triad
  • Hypotension
  • Distended neck veins (JVD)
  • Muffled heart sounds
  • (Classic but not always present)
284.1.0.1.4.3 Pulsus Paradoxus

  • 10 mmHg fall in SBP on inspiration

  • Mechanism: inspiration ↑ RV filling → bulges septum → ↓ LV filling
  • DDx: severe asthma, COPD, PE, RV infarct, constrictive (rarely)
284.1.0.1.4.4 Kussmaul Sign
  • JVP ↑ with inspiration (paradoxical)
  • More common in constrictive pericarditis than tamponade
284.1.0.1.4.5 ECG
  • Low voltage
  • Electrical alternans (beat-to-beat QRS amplitude variation — swinging heart)
  • Sinus tachycardia
284.1.0.1.4.6 Echocardiogram
  • RA collapse during late diastole (most sensitive)
  • RV collapse during early diastole (most specific)
  • IVC plethora (no respiratory variation)
  • Respiratory variation > 25% in MV inflow E wave
  • Septal bounce
  • Swinging heart
284.1.0.1.4.7 Treatment
  • Emergency pericardiocentesis
  • IV fluids, vasopressors as bridge
  • Avoid mechanical ventilation if possible (decreases preload)
  • Address underlying cause
284.1.0.1.5 Constrictive Pericarditis
284.1.0.1.5.1 Pathophysiology
  • Thickened, fibrotic, sometimes calcified pericardium
  • Restricts ventricular filling in diastole
  • “Square root sign” (dip and plateau) on cath
  • Ventricular interdependence (septal bounce)
284.1.0.1.5.2 Etiologies
  • Idiopathic / post-viral (common in developed)
  • Post-cardiac surgery (CABG, valve)
  • Radiation (Hodgkin’s, breast cancer)
  • TB (most common globally, especially Africa, Asia)
  • Connective tissue disease
  • Uremic
  • Asbestos
  • Sarcoidosis
284.1.0.1.5.3 Clinical
  • Right HF predominant: edema, ascites, hepatomegaly, JVD
  • Dyspnea
  • Cachexia
  • Atrial fibrillation common
  • Pulsus paradoxus rare
  • Kussmaul sign
  • Pericardial knock (early diastolic, S3-like)
284.1.0.1.5.4 Diagnosis
  • Echo:
    • Septal bounce (respiratory variation of septum)
    • Respiratory variation > 25% in MV inflow E
    • Annulus reversus (medial e’ > lateral e’ — opposite of restrictive)
    • Preserved or accentuated tissue Doppler e’ (vs restrictive)
  • CT / CMR:
    • Pericardial thickness > 4 mm (CMR is best)
    • Calcification (CT)
    • Septal bounce on cine
  • RHC:
    • Square root sign (early diastolic dip + plateau)
    • Equalization of all chambers
    • Ventricular interdependence (LV-RV systolic discordance)
284.1.0.1.5.5 Constrictive vs Restrictive Cardiomyopathy
Feature Constrictive Restrictive
Pericardial thickening Yes (> 4 mm) No
Calcification Common No
Tissue Doppler e’ Preserved/↑ Reduced
Annulus Annulus reversus Annulus paradoxus
Ventricular interdependence Yes No
BNP Modest ↑ Marked ↑
Treatment Pericardiectomy Treat amyloid/storage
284.1.0.1.5.6 Treatment
  • Pericardiectomy = definitive (radical preferred)
  • High morbidity/mortality (5-15%)
  • Diuretics for symptoms
  • Treat underlying disease
284.1.0.1.6 Effusive-Constrictive Pericarditis
  • Effusion + constrictive physiology
  • Pericardiocentesis relieves effusion partially but constriction remains
  • TB common cause
  • Treat constriction (pericardiectomy) if persistent

284.1.0.2 🩺 床邊速查

  • Acute pericarditis dx: 2 of 4 (pleuritic pain + rub + ECG + effusion)
  • ECG: diffuse ST↑ + PR↓ in pericarditis (vs localized STEMI)
  • Treatment: NSAID + colchicine 3 mo (CORP, ICAP)
  • Recurrent pericarditis: rilonacept (RHAPSODY), anakinra; avoid steroids first
  • Tamponade: Beck triad + pulsus paradoxus + echo (RA/RV collapse, IVC plethora)
  • Constrictive vs restrictive: tissue Doppler e’ (preserved in constrictive); pericardiectomy is cure