Pericarditis & Cardiac Tamponade Nursing Guide

Acute Pericarditis

Inflammation of the pericardium (fibroserous sac surrounding the heart). Most common cardiac inflammatory condition.

Causes

Viral (80%) — Coxsackievirus B, echovirus, adenovirus, EBV, CMV, COVID-19
Bacterial (TB — most common in GCC expat populations; purulent)
Post-MI (Dressler's syndrome — 2–6 weeks post-MI)
Post-cardiac surgery
Autoimmune: SLE, rheumatoid arthritis
Uraemic pericarditis (renal failure)
Malignancy

Diagnosis — 2 of 4 Criteria

Pleuritic chest pain (sharp, improved leaning forward/sitting up, worse lying flat)
Pericardial friction rub (scratchy leathery sound, best heard at left lower sternal edge, end expiration, leaning forward)
Widespread concave ("saddle-shaped") ST elevation on ECG ± PR depression
New or worsening pericardial effusion on echo

ECG Stages of Pericarditis

Stage	Timing	ECG Changes
Stage I	Hours–days	Diffuse saddle-shaped ST elevation in multiple leads; PR depression
Stage II	Days–weeks	ST normalises; T wave flattening
Stage III	Weeks	T wave inversion
Stage IV	Weeks–months	ECG normalises

Pericarditis vs STEMI ECG differentiation:
• Pericarditis: diffuse ST elevation in MULTIPLE leads (not territory); concave (saddle-shaped) upward; PR depression; no reciprocal ST depression (except aVR)
• STEMI: ST elevation in specific territory (anterior/inferior/lateral); convex (dome-shaped); reciprocal ST depression in opposite leads

Cardiac Tamponade — Medical Emergency

Accumulation of pericardial fluid under pressure → compresses cardiac chambers → reduced cardiac output → obstructive shock → cardiac arrest.

Hypotension
↓ cardiac output

Raised JVP
↑ venous pressure

Muffled heart sounds
fluid damping

Beck's Triad of Cardiac Tamponade

Additional Signs

Pulsus paradoxus — SBP falls >10 mmHg during inspiration (exaggerated due to septal shift)
Tachycardia (compensatory)
Dyspnoea, anxiety, low SpO₂
Kussmaul's sign (JVP rises on inspiration — opposite of normal)
Electrical alternans on ECG (alternating QRS amplitude from heart swinging in fluid)
"Globular" enlarged cardiac silhouette on CXR (fluid accumulation)

Emergency Management:
1. Pericardiocentesis (drain pericardial fluid) — lifesaving. Needle inserted at 45° angle at xiphoid, pointing towards left shoulder under echo or fluoroscopy guidance.
2. IV fluids as temporising measure to maintain preload
3. Avoid PPV if possible (positive pressure reduces preload, worsens tamponade)
4. Surgical pericardial window if recurrent

Treatment of Acute Pericarditis

First-Line Therapy

Aspirin 750–1000mg TDS × 1–2 weeks, then taper (or NSAIDs — ibuprofen 600mg TDS)
Colchicine 0.5mg BD × 3 months (reduces recurrence rate by 50%)

Colchicine is the most important addition to NSAID therapy — proven to reduce recurrence in the COPE, CORE, and ICAP trials. Always prescribe colchicine alongside NSAIDs unless contraindicated.

Activity Restriction

Non-athletes: restrict strenuous activity until symptoms resolve and CRP normalises
Athletes: rest for ≥3 months, return to sport only after clinical/echo/CRP normalisation

Corticosteroids — When to Use

Only if: NSAID/colchicine failure, contraindications to NSAIDs, autoimmune or uraemic pericarditis
Not first-line — associated with higher recurrence rate
Low-dose prednisolone 0.25–0.5 mg/kg/day with slow taper

Constrictive Pericarditis

Chronic complication from organised pericardial fibrosis following recurrent/inadequately treated pericarditis. Features: right heart failure (JVP, peripheral oedema, ascites), Kussmaul's sign, pericardial knock (3rd heart sound). Treatment: pericardiectomy.

Dressler's Syndrome

Post-cardiac injury pericarditis: occurs 2–6 weeks post-MI, post-cardiac surgery, or post-pericardiocentesis. Autoimmune mechanism. Features: fever, pleuritic chest pain, pericardial effusion, raised ESR/CRP. Treatment: aspirin, NSAIDs, colchicine.

GCC-Specific Pericarditis Context

Tuberculous pericarditis — TB is a significant cause of pericarditis and constrictive pericarditis in GCC countries, particularly in South Asian and East African expat workers. TB pericarditis presents with large exudative effusion, haemorrhagic fluid, constitutional symptoms (fever, weight loss, night sweats). Treat with standard 4-drug RIPE regimen × 6 months + corticosteroids (prednisolone) to reduce constrictive progression (questionable evidence).
Uraemic pericarditis — with high rates of CKD/ESRD from diabetic nephropathy in GCC, uraemic pericarditis (BUN >60 mg/dL) is seen. Treatment: intensified haemodialysis. NSAIDs are avoided in renal failure.
Post-COVID pericarditis — COVID-19 myopericarditis is now well-recognised. GCC countries experienced COVID-19 surges and post-COVID pericarditis cases. Young male patients with pleuritic chest pain and elevated troponin post-COVID should have echo to exclude pericardial effusion.
NSAIDs in GCC patients — high rates of peptic ulcer disease and renal disease in GCC. Prescribe NSAIDs with PPI cover. Avoid in eGFR <30 mL/min. Aspirin preferred in post-MI patients (antiplatelet already indicated).

MCQ Practice — Pericarditis

Q1. A 32-year-old man presents with sharp chest pain that is worse lying flat and improves leaning forward. ECG shows diffuse saddle-shaped ST elevation with PR depression. What is the diagnosis and first-line treatment?

A) STEMI — urgent primary PCI

B) Acute pericarditis — aspirin/ibuprofen + colchicine

C) Aortic dissection — IV labetalol + urgent CT

D) Pulmonary embolism — anticoagulation

✅ B — Pleuritic chest pain (better sitting forward) + saddle-shaped diffuse ST elevation + PR depression = acute pericarditis. Treatment: ibuprofen/aspirin + colchicine for 3 months. Pericarditis ECG is diffuse (all leads) vs STEMI (territorial). Colchicine reduces recurrence by 50%.

Q2. A patient with large pericardial effusion develops hypotension, raised JVP, and muffled heart sounds. What is this clinical syndrome called?

A) Dressler's syndrome

B) Constrictive pericarditis

C) Pulmonary oedema

D) Cardiac tamponade — Beck's Triad

✅ D — Beck's Triad: Hypotension + Raised JVP + Muffled heart sounds = Cardiac tamponade. Emergency pericardiocentesis is required. Pulsus paradoxus and electrical alternans on ECG are additional features. Constrictive pericarditis causes a similar presentation but chronically.

Q3. Which drug reduces pericarditis recurrence rates by approximately 50% when added to NSAID therapy?

A) Prednisolone

B) Azithromycin

C) Colchicine

D) Hydroxychloroquine

✅ C — Colchicine 0.5mg BD × 3 months significantly reduces recurrence of pericarditis (COPE and CORE trials). Corticosteroids are NOT first-line and are associated with HIGHER recurrence rates. Colchicine is now standard of care alongside NSAIDs.

Q4. Electrical alternans on ECG (alternating QRS amplitude) is a sign of which condition?

A) Constrictive pericarditis

B) Acute pericarditis

C) Right bundle branch block

D) Cardiac tamponade (large pericardial effusion)

✅ D — Electrical alternans (beat-to-beat alternation in QRS height) is caused by the heart swinging back and forth within a large pericardial effusion. It is pathognomonic of significant pericardial effusion and tamponade physiology. Emergency echocardiogram and pericardiocentesis required.

Pericarditis & Cardiac Tamponade — Nursing Guide