📌 Postpericardiotomy SyndromeFever, pericarditis, pleural effusion 1-6 weeks after cardiac surgery. Self-limited. NSAIDs, colchicine, corticosteroids for severe. Aspirin for children.
📌 Purulent (Bacterial) PericarditisAcute, toxic appearance, high fever, tamponade. Emergent pericardiocentesis + IV antibiotics. Often S. aureus, S. pneumoniae, H. influenzae. Post-pneumonia or post-op.
📌 Management – Acute PericarditisNSAIDs (ibuprofen, indomethacin) first-line. Aspirin if postpericardiotomy. Colchicine for recurrent pericarditis. Corticosteroids reserved for refractory/autoimmune (risk of chronicity).
📌 Indications for PericardiocentesisCardiac tamponade (emergent). Purulent pericarditis. Suspected neoplastic or tuberculous etiology. Large effusion with symptoms. Diagnostic if unclear.
🔍 Step 1: Recognize chest pain characteristics Sharp, pleuritic, retrosternal, worse supine, relieved by sitting forward. Radiates to shoulders, neck. May mimic myocardial infarction.
📈 Step 2: Physical examination Pericardial friction rub (scratchy, to-and-fro, best heard at LLSB with patient leaning forward). Fever, tachycardia. Muffled heart sounds if effusion.
🩺 Step 3: ECG findings Diffuse ST elevation (concave up) in I, II, aVF, V2-V6. PR depression. Reciprocal ST depression only in aVR. No Q waves (differentiate from MI).
🔄 Step 4: Echocardiogram Assess for pericardial effusion, signs of tamponade (RV collapse, IVC plethora). Differentiate from myocarditis (wall motion abnormalities).
1️⃣ Acute pericarditis – Medical therapy ▪ NSAIDs: ibuprofen 30-50 mg/kg/day (max 2.4 g/day) for 1-2 weeks, taper. ▪ Aspirin: 50 mg/kg/day (postpericardiotomy). ▪ Colchicine: 0.5-1 mg/day (≥12 years) for recurrent pericarditis (reduces recurrence). ▪ Corticosteroids: avoid if possible (reserved for refractory, autoimmune).
2️⃣ Pericardial effusion – No tamponade ▪ Small/moderate asymptomatic: observe, treat underlying cause. ▪ Repeat echo in 1-2 weeks. ▪ Avoid NSAIDs if suspected TB (may mask symptoms).
3️⃣ Cardiac tamponade – Emergent treatment ▪ Pericardiocentesis (echo-guided) – diagnostic + therapeutic. ▪ IV fluids (increase preload). Avoid diuretics, vasodilators. ▪ Surgical pericardial window if recurrent or loculated effusion. ▪ Treat underlying cause (bacterial: antibiotics).
4️⃣ Purulent (Bacterial) Pericarditis ▪ Emergent pericardiocentesis + drain placement. ▪ IV antibiotics: vancomycin + third-generation cephalosporin (cover S. aureus, S. pneumoniae, H. influenzae). ▪ Surgical drainage if loculated.
5️⃣ Constrictive Pericarditis ▪ Pericardiectomy (surgical resection of pericardium). ▪ Medical therapy: diuretics for volume overload (temporizing). ▪ Treat TB if causative (antitubercular therapy).
6️⃣ Postpericardiotomy Syndrome ▪ Aspirin (50 mg/kg/day) or NSAIDs. ▪ Colchicine (if recurrent). ▪ Corticosteroids for severe (prednisone 1 mg/kg/day).
7️⃣ Transition & long-term follow-up ▪ Recurrent pericarditis: colchicine long-term. Refractory: anakinra (IL-1 inhibitor). ▪ Constrictive pericarditis: lifelong follow-up for HF. ▪ Transition to adult cardiology for chronic or recurrent cases.
❓ Reflex prompt 1: A 12-year-old with sharp chest pain, worse lying down, better leaning forward. ECG: diffuse ST elevation, PR depression. Most likely diagnosis? ✅ Answer: Acute pericarditis. Treat with NSAIDs (ibuprofen). Echocardiogram to exclude effusion.
❓ Reflex prompt 2: A 6-year-old post-cardiac surgery day 10 presents with fever, chest pain, friction rub. Diagnosis and treatment? ✅ Answer: Postpericardiotomy syndrome. Aspirin (or NSAIDs). Self-limited, good prognosis.
❓ Reflex prompt 3: A 14-year-old with pericardial effusion, hypotension, muffled heart sounds, and JVD. Next immediate step? ✅ Answer: Cardiac tamponade → emergent pericardiocentesis. IV fluids while preparing.
❓ Reflex prompt 4: A 10-year-old with recurrent pericarditis, failed NSAIDs and colchicine. Next step? ✅ Answer: Anakinra (IL-1 receptor antagonist) or corticosteroids. Evaluate for underlying autoimmune disease.
❓ Reflex prompt 5: A 5-year-old with high fever, toxic appearance, and pericardial rub. Echo shows large effusion. Next step? ✅ Answer: Purulent pericarditis. Emergent pericardiocentesis + IV antibiotics (vancomycin + ceftriaxone).
❓ Reflex prompt 6: A 16-year-old with chronic constrictive pericarditis after TB. Symptoms: ascites, pedal edema, JVP 18 cm H2O. Treatment? ✅ Answer: Pericardiectomy. Anti-TB therapy. Diuretics for symptom relief preoperatively.
📌 Diseases of the Pericardium – Core Concepts (Nelson 22e, Chapter 489)
1. Acute Pericarditis: Inflammation of pericardium. Most common etiology: viral (coxsackie, echo, adenovirus, influenza, EBV, CMV, COVID-19). Others: idiopathic, bacterial, postpericardiotomy, autoimmune (SLE, JIA), uremic, neoplastic. 2. Clinical triad: Chest pain (sharp, pleuritic, positional), pericardial friction rub (pathognomonic), fever. 3. ECG stages: Stage I: diffuse ST elevation, PR depression. Stage II: normalization. Stage III: T-wave inversion. Stage IV: normal. 4. Echocardiogram: Pericardial effusion (echo-free space). Signs of tamponade: RV/RA collapse, IVC plethora, respiratory variation in Doppler inflow. 5. Cardiac tamponade – Beck's triad: Hypotension, JVD, muffled heart sounds. Pulsus paradoxus >10 mmHg. Emergent pericardiocentesis. 6. Constrictive pericarditis: Thickened, calcified pericardium → impaired diastolic filling. Symptoms: right-sided HF (JVD, hepatomegaly, ascites, edema). Kussmaul sign (JVP rises with inspiration). Pericardiectomy definitive treatment. 7. Postpericardiotomy syndrome: 1-6 weeks post-cardiac surgery. Fever, pericarditis, pleural effusion. Self-limited. Treat with aspirin/NSAIDs. 8. Purulent pericarditis: Bacterial (S. aureus, S. pneumoniae, H. influenzae). Toxic appearance, tamponade. Emergent pericardiocentesis + IV antibiotics. 9. Treatment – Acute pericarditis:
- NSAIDs (ibuprofen, indomethacin) first-line. Aspirin for postpericardiotomy.
- Colchicine for recurrent pericarditis (reduces recurrence rate).
- Corticosteroids reserved for refractory or autoimmune (risk of chronicity). 10. Pericardiocentesis indications: Cardiac tamponade (emergent), purulent pericarditis, diagnostic for TB/malignancy, large symptomatic effusion. 💡 Clinical pearls:
➤ Pericardial friction rub may be transient; listen with patient leaning forward, breath held in expiration.
➤ Differentiate pericarditis from myocarditis: myocarditis has elevated troponin, wall motion abnormalities on echo, LGE on MRI.
➤ Tamponade: pulsus paradoxus may be absent in LV dysfunction or ASD.
➤ Avoid NSAIDs in suspected TB pericarditis (may mask symptoms).
➤ Recurrent pericarditis: colchicine reduces recurrence; anakinra for refractory cases.