Listen to this patient's heart.
Obtain a history of:
· Precordial pain changing with posture (worse on lying down and relieved by sitting forward).
· Myocardial infarction.
· Viral infection (Coxsackie A and B viruses).
· Chronic renal failure.
· Scratching and grating sound heard best with the diaphragm at the left sternal border, with the patient leaning forward and the breath held in expiration. Note. A pericardial rub does not occur in acute pericarditis and it is common for the rub to disappear when a pericardial effusion develops.
· Tell the examiner that you would like to do an ECG (see below).
This patient has a pericardial rub (lesion) resulting from pericarditis secondary to uraemia (aetiology) and is not in pain (functional status).
What are the characteristic features of a pericardial friction rub?
It typically consists of three components: a presystolic rub (during atrial contrac-tion), a ventricular
systolic rub (which is almost always present and usually the loudest component) and a diastolic rub which follows the second heart sound (during rapid ventricular filling).
What are the characteristic electrocardiographic findings?
· ST elevation in most ECG leads with the concavity upwards.
· T-wave inversion occurs after the ST segment returns to baseline (unlike in acute myocardial infarction
where the ST segment is concave downwards like a cat's
back and there is some amount of T-wave inversion accompanying the ST elevation).
· PR-segment depression (due to inflammation of the atrial wall).
How common is pericardial rub in constrictive pericarditis?
It is not heard in constrictive pericarditis.
What is the treatment for acute pericarditis?
· Pain relief (codeine) and anti-inflammatory agents (non-steroidal anti-inflammatory drugs (NSAIDs)
such as indometacin).
· Steroids should be considered only when the pain does not respond to a com-bination of NSAIDs.
· Treatment of the underlying cause.
· Colchicine has been used to treat recurrent pain of pericarditis, and rarely peri-cardiectomy may be required for pain even in the setting of no haemodynamic impairment.
What do you know about the transient constrictive phase of acute
About 10% of the patients with acute pericarditis have a transient constrictive phase which may last 2-3 months before it gradually resolves, either spontaneously or with treatment with anti-inflammatory drugs.
These patients usually have a mod-erate amount of pericardial effusion and, as the effusion resolves, the pericardium remains thickened, inflamed and non-compliant resulting in constrictive haemo-dynamics.
Clinical features include shortness of breath, raised jugular venous pressure, peripheral oedema and ascites. Constrictive haemodynamics can be documented by Doppler echocardiography and resolution of constrictive physiology can be serially followed by this technique.
What is Dressler's syndrome?
Dressler's syndrome is characterized by persistent pyrexia, pericarditis and pleurisy. It was first described in 1956 when Dressier recognized that post-myocardial infarction chest pain is not caused by coronary artery insufficiency. It usually occurs 2-3 weeks after myocardial infarction and is considered to be of autoimmune aetiology; it responds to NSAIDs.
What do you know about postcardiotomy syndrome?
It occurs in about 5% of patients who have cardiac surgery, with symptoms of pericarditis from three weeks to six months after surgery. It is initially treated with NSAIDs and systemic steroids in refractory cases. Pericardiectomy is rarely required. It is said to result from an autoimmune response and is most likely to be related to surgical trauma and irritation of blood products in the mediastinum and pericardium.
What are the functions of pericardium?
· The pericardium protects and lubricates the heart.
· It contributes to the diastolic coupling of the left and right ventricles - an effect that is important in
cardiac tamponade and constrictive pericarditis.
W. Dressier (1890-1969), US physician educated in Vienna. He worked at the I
Manimoides Hospital, Brooklyn, New York.