CARDIOLOGY
PERICARDITIS
PromptClinical features of pericarditis
Responsepositional, typically worse lying flat and relieved sitting forward
sharp, stabbing nature.
radiates to left trapezius ridge
associated with a rub
sharp, stabbing nature.
radiates to left trapezius ridge
associated with a rub
PromptList differential for pleuritic central chest pain and investigations to differentiate these
ResponsePneumonia - CXR
PE - d-dimer (no marks for CTPA)
Pneumothorax- CXR or lung ultrasound
Aortic dissection - CT angiogram
MI/myocarditis - Troponin/echo
Pericarditis
PE - d-dimer (no marks for CTPA)
Pneumothorax- CXR or lung ultrasound
Aortic dissection - CT angiogram
MI/myocarditis - Troponin/echo
Pericarditis
PromptECG (interpret)
Response
PromptECG describe classic findings
ResponseANSWERS:
Sinus tachycardia
Widespread concave ST elevation and PR depression is present throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF).
Reciprocal ST depression and PR elevation in V1 and aVR.
Acute pericarditis / myocarditis - Widespread STE not conforming to one anatomical region - Saddle shaped STE – ECHO = No RWMA, presence of pericardial effusion
Sinus tachycardia
Widespread concave ST elevation and PR depression is present throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF).
Reciprocal ST depression and PR elevation in V1 and aVR.
Acute pericarditis / myocarditis - Widespread STE not conforming to one anatomical region - Saddle shaped STE – ECHO = No RWMA, presence of pericardial effusion
Prompt4 stages of ECG changes
ResponseStage 1 – widespread concave up STE and PR depression (with reciprocal changes in aVR) occurs during the first two weeks.
Stage 2 – normalisation of ST changes; generalised T wave flattening , 1 to 3 weeks.
Stage 3 – flattened T waves become inverted 3 to several weeks.
Stage 4 – ECG returns to normal, several weeks onwards, but TW may stay inverted. (Less than 50% of patients progress through all four classical stages and evolution of changes may not follow this typical pattern.)
Stage 2 – normalisation of ST changes; generalised T wave flattening , 1 to 3 weeks.
Stage 3 – flattened T waves become inverted 3 to several weeks.
Stage 4 – ECG returns to normal, several weeks onwards, but TW may stay inverted. (Less than 50% of patients progress through all four classical stages and evolution of changes may not follow this typical pattern.)
PromptDifferential for Pericarditis ECG’s
Response
PromptCauses of Pericarditis + investigations for each
Note this answer is overly complicated. Usually do not want so much detail. I have compiled about 5 answers here for this – Good to know at least 2 bacteria and 2 viral causes but they want breadth not depth.
Note this answer is overly complicated. Usually do not want so much detail. I have compiled about 5 answers here for this – Good to know at least 2 bacteria and 2 viral causes but they want breadth not depth.
ResponseIdiopathic
Infectious
Malignant (25%) – including Paraneoplastic syndromes
Post-myocardial infarction or following cardiac surgery (Dressler’s syndrome) -Trauma
Drug-induced (e.g. isoniazid, cyclosporin)
Post-radiotherapy
SLICKER LIST:
Infectious
- Viral (coxsackie) - usually no testing needed, PCR, serology (Enterovirus, adenovirus, Mumps, EBV, VZV, Hep B, Flu, HIV)
- Bacterial - bc if patient febrile (S. Aureus, Pneumococci, strep, legionella, Salmonella)
- Tb - if contact history or from high risk group - mantoux cxr Acid Fast bacilli sputum stain, Quantiferon gold
- SLE / rheumatoid - if other symptoms or family history and no other cause apparent -
- Ana screen / complement 1-2
- Rheum factor / crp
Malignant (25%) – including Paraneoplastic syndromes
- lung Ca, if other symptoms or signs suggestive - CT chest / abdomen as appropriate to suspected source.
Post-myocardial infarction or following cardiac surgery (Dressler’s syndrome) -Trauma
Drug-induced (e.g. isoniazid, cyclosporin)
Post-radiotherapy
SLICKER LIST:
- Viral – Enterovirus /Adenovirus / EBV / Mumps
- Bacterial – Staph aureus / Streptococci / Pneumococci / Legionella / TB
- Malignancy – lung / Breast / Leukaemia/ Lymphoma/Melanoma
- Autoimmune – RA / SLE / Dressler’s syndrome
- Uraemia
- Serum sickness
- Post Myocardial Infarction (post cardiac surgery/chest radiation) – Dressler’s syndrome
PromptPericarditis investigations
ResponseEcho - No RWMA, presence of pericardial effusion
Troponin/CK
MRI
Troponin/CK
MRI
PromptPericardial effusion investigations
ResponseECG – low voltage QRS complexes
CXR – globular shaped heart
ECHO – fluid seen as a black stripe,
CXR – globular shaped heart
ECHO – fluid seen as a black stripe,
PromptPrescribe a drug treatment for pericarditis
ResponseColchicine 500 mcg BD for 3 months
- Plus -
Ibuprofen 600 mg TDS for 1-2 weeks then taper
- Or –
Aspirin 750-1000 mg TDS for 1-2 weeks then taper
- Plus -
Ibuprofen 600 mg TDS for 1-2 weeks then taper
- Or –
Aspirin 750-1000 mg TDS for 1-2 weeks then taper
PromptBenign early repolarisation ECG criteria - Describe
ResponseST elevation limited to the precordial leads
Absence of PR depression
Prominent T waves
Changes do not evolve over time
Absence of PR depression
Prominent T waves
Changes do not evolve over time