1. Acute Pericarditis

1.1 Epidemiology

• Incidence:
  • Acute pericarditis accounts for approximately 5% of all acute chest pain admissions.
• Clinical Relevance:
  • Despite its similarity in presentation to acute coronary syndromes, pericarditis is managed differently.

1.2 Aetiology

• Primary (Idiopathic) Pericarditis:
  • The cause often remains unknown.
  • Frequently follows a viral infection by several weeks.
• Secondary Causes:
  • Trauma (e.g. seatbelt injury)
  • Uraemia (in renal failure)
  • Myocardial Infarction (Dressler’s syndrome)
  • Other infections: Viral (e.g. Epstein–Barr virus, CMV, HIV, Coxsackie virus), bacterial (e.g. tuberculosis, rheumatic fever), fungal.
  • Autoimmune and Inflammatory Disorders: Rheumatoid arthritis, systemic lupus erythematosus, radiation.
  • Surgical Causes: Post-coronary artery bypass graft surgery.

1.3 Risk Factors

• Preceding Infection: A recent viral illness is a recognised trigger.
• Uraemia: Seen in patients with renal failure.
• Post-Myocardial Infarction: Dressler’s syndrome is a recognised complication.
• Autoimmune Disorders: Conditions such as rheumatoid arthritis and lupus increase risk.
• Post-Surgical Status: Cardiac surgery may precipitate pericardial inflammation.

1.4 Symptoms

• Chest Pain:
  • Typically pleuritic in nature – a sharp, stabbing or burning pain.
  • Pain is exacerbated by lying flat and relieved by sitting upright (due to the heart’s position within the pericardial sac).
• Respiratory Symptoms:
  • Patients are often tachypnoeic and take shallow, rapid breaths to avoid painful deep inspiration.
• Associated Features:
  • A pericardial rub may be heard on auscultation along the lower left sternal edge.
  • If myocardial involvement occurs (myopericarditis), signs of heart failure may be present.

1.5 Diagnosis

• Clinical History and Examination:
  • Diagnosis is primarily based on the characteristic chest pain and positional nature of the pain.
  • A pericardial rub is an important physical finding.
• Blood Tests:
  • Inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white cell count are typically elevated.
  • Cardiac enzymes (e.g. troponin) may be raised if there is concomitant myocardial involvement.
• Electrocardiography (ECG):
  • If the myocardium is involved, the ECG may show:
    • Concave, ‘saddle-shaped’ ST-segment elevation.
    • Tall T waves.
    • PR-segment depression (especially if the atrial myocardium is affected).
  • Importantly, the ST-segment elevation in pericarditis is diffuse and not confined to a single coronary territory.
• Chest X-ray:
  • An enlarged, globular cardiac silhouette may indicate a pericardial effusion.
• Echocardiography:
  • Performed in all cases to exclude or assess for pericardial effusion and to evaluate myocardial systolic function.

1.6 Immediate Management

• Idiopathic Pericarditis:
  • Reassurance and Analgesia: Patient education and symptomatic relief.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
    • Common agents include aspirin or colchicine.
  • Rest: Advising the patient to limit physical activity during the acute phase.
• Pericarditis with Effusion:
  • Pericardiocentesis is indicated when there is evidence of cardiac tamponade (a clinical emergency) or when diagnostic analysis of the fluid is needed.
• Myocarditis Involvement:
  • If myocardial involvement is suspected, a cardiac MRI should be performed to assess the degree of myocardial inflammation and damage.
  • These patients may require heart failure therapy and closer monitoring.

1.7 Long-Term Management

• Recurrence Prevention:
  • Colchicine is often used to treat recurrent pericarditis.
• Monitoring:
  • Regular follow-up is required to monitor for the development of pericardial scarring or constrictive pericarditis, which can impair diastolic function.
• Management of Underlying Causes:
  • If pericarditis is secondary, treat the underlying condition (e.g. dialysis for uraemia, antimicrobials for tuberculosis).
• Follow-Up Imaging:
  • Periodic echocardiography may be necessary to monitor for changes in effusion size or myocardial function.

2. Pericardial Effusion

2.1 Epidemiology

• Uncommon Condition: Pericardial effusion is an infrequent clinical finding.
• Clinical Context: It may occur in various settings, including following invasive cardiac procedures where patients become acutely unwell with low blood pressure.

2.2 Aetiology

• Definition: The condition is defined as the collection of fluid in the space between the visceral and parietal pericardial layers.
• Multiple Causes:
  • Acute pericarditis (idiopathic or post-viral)
  • Myocardial infarction
  • Trauma
  • Post-cardiac surgery or intervention (e.g. CABG, EP, PCI)
  • Aortic dissection
  • Malignancy
  • Renal failure (uraemic effusion)
  • Infection:
    • Viral (e.g. Coxsackievirus, Echovirus, Cytomegalovirus, HIV)
    • Bacterial (e.g. Tuberculosis)
  • Autoimmune diseases (e.g. rheumatoid arthritis, systemic lupus erythematosus)

2.3 Risk Factors

• Underlying Pathologies: Risk of pericardial effusion increases with conditions that cause pericardial inflammation or injury, such as:
  • Recent viral infections leading to pericarditis.
  • Cardiac surgery or interventional procedures.
  • Systemic conditions (e.g. renal failure, malignancy, autoimmune disorders).
• Haemodynamic Factors:
  • The rate of fluid accumulation is critical; a rapid, low-volume accumulation may precipitate cardiac tamponade, whereas a slowly developing effusion can reach large volumes without immediate haemodynamic compromise.

2.4 Symptoms

• Small or Chronic Effusions:
  • Patients are often asymptomatic.
• Large Effusions:
  • Dyspnoea and chest pain may develop.
• Cardiac Tamponade:
  • When the effusion acutely compromises cardiac filling, patients may present in extremis or following cardiac arrest.

2.5 Diagnosis

• Clinical Assessment:
  • History and Examination: Consider pericardial effusion in patients with recent invasive cardiac procedures who become acutely unwell with hypotension.
  • Physical Findings:
    • Elevated jugular venous pressure (JVP)
    • Hypotension
    • An impalpable apex beat
    • Tachycardia and tachypnoea
    • Pulsus paradoxus (abnormal decrease in pulse volume on inspiration)
    • Kussmaul’s sign (abnormal rise in JVP with inspiration)
• Electrocardiography (ECG):
  • Small QRS Complexes: Due to the insulating effect of the pericardial fluid.
  • Electrical Alternans: The cardiac axis alternates as the heart swings within a large effusion.
• Chest X-Ray:
  • Shows an enlarged, globular cardiac silhouette.
• Echocardiography:
  • Confirmation of the diagnosis is made by demonstrating the fluid collection between the visceral and parietal pericardium.
  • Assesses the hemodynamic impact, such as evidence of tamponade.

2.6 Immediate Management

• Management Depends on Severity:
  • Cardiac Tamponade:
    • Requires emergency pericardiocentesis to drain the fluid.
    • It is not unusual to drain more than 2 litres from a large effusion.
  • Stable Patients with Small Effusions:
    • Managed conservatively with diuretic therapy.
• Additional Considerations:
  • Management should also focus on treating the underlying cause (e.g. addressing infection, managing renal failure, or post-surgical care).

2.7 Long-Term Management

• Monitoring:
  • Patients managed conservatively are followed with serial echocardiography until the effusion resolves.
• Underlying Cause Treatment:
  • Definitive management is directed at the underlying aetiology to prevent recurrence.
• Follow-Up:
  • Regular clinical reviews to assess symptoms and any changes in haemodynamic status.

2.8 Complications

• Cardiac Tamponade:
  • Life-threatening haemodynamic compromise due to rapid accumulation of fluid.
• Progressive Haemodynamic Deterioration:
  • Even a small, rapidly accumulating effusion can cause significant compromise.
• Chronic Effusions:
  • May lead to constrictive pericarditis if scarring and fibrosis develop over time.

3. Cardiac Tumours

3.1 Epidemiology

• Rarity: All primary cardiac tumours are rare.
• Classification:
  • Benign tumours (e.g. myxomas, rhabdomyomas, lipomas, fibro‑mas) are more common than primary malignant tumours and are generally not life‑threatening.
  • Primary malignant tumours (e.g. rhabdomyosarcomas, angiosarcomas, myxosarcomas, fibrosarcomas, leiomyosarcomas) are approximately four times rarer than benign types.
  • Secondary tumours (metastases) are almost always malignant and carry a very poor prognosis.
• Cardiac Myxoma Specifics:
  • Occurs in approximately 1 in 5000 adults.
  • Affects about 75% women.
  • Most frequently arises in the left atrium.

3.2 Aetiology

• Primary Tumours:
  • Benign Tumours:
    • Myxomas: Benign mesenchymal tumours with a gelatinous appearance and abundant ground substance on histology.
    • Other benign tumours include rhabdomyomas (most common in children, often associated with tuberous sclerosis), lipomas and fibromas.
  • Malignant Tumours:
    • Primary malignant tumours such as rhabdomyosarcomas, angiosarcomas, myxosarcomas, fibrosarcomas and leiomyosarcomas.
• Secondary Tumours:
  • Result from metastases from distant primary sites (e.g. breast carcinoma, lung carcinoma, melanoma, lymphoma).
  • These tumours are malignant and generally have a very poor prognosis.

3.3 Risk Factors

• For Primary Benign Tumours (e.g. Myxoma):
  • Female gender
• For Primary Malignant Tumours:
  • Family history of cardiac tumours (genetic predisposition)
  • Advanced age
  • Chest irradiation
  • Certain genetic syndromes
• For Secondary (Metastatic) Tumours:
  • Presence of an aggressive primary cancer (e.g. breast or lung carcinoma, melanoma, lymphoma) is the key risk factor.

3.4 Symptoms

• General Presentation:
  • Many cardiac tumours are asymptomatic and discovered incidentally during echocardiography.
• Constitutional Symptoms (common in myxomas):
  • Weight loss, malaise, fever, and night sweats.
• Local Effects:
  • A tumour may interfere with valve function, causing a murmur.
  • In the case of a cardiac myxoma, a characteristic ‘diastolic plop’ may be heard if a semi‑mobile mass prolapses through the mitral valve annulus, potentially causing syncope.
• Other Presentations:
  • Rhabdomyomas in children may present with arrhythmias or signs of heart failure and are often associated with tuberous sclerosis.
• Malignant Tumours:
  • May present with signs of systemic spread and are more likely to recur after treatment.

3.5 Diagnosis

• Imaging Modalities:
  • Echocardiography:
    • The primary investigation for cardiac tumours.
    • Transthoracic echo typically identifies a mobile, pedunculated mass, most commonly in the left atrium (e.g. myxoma).
    • Transoesophageal echo provides greater detail regarding the size and attachment site of the tumour.
  • CT and MRI Scanning:
    • Used to define the tumour’s extent, location, and degree of invasiveness.
• Histological Examination:
  • May be required for definitive diagnosis, particularly to distinguish between benign and malignant tumours.
  • For example, myxomas show a benign mesenchymal appearance with abundant ground substance.

3.6 Immediate Management

• Benign Tumours:
  • Surgical Removal:
    • Indicated for symptomatic tumours, particularly if they interfere with valve function (e.g. causing a diastolic plop or syncope).
    • Once removed, benign tumours rarely recur.
• Malignant Tumours:
  • Palliative Management:
    • Treatment is usually palliative due to the tendency of malignant tumours to spread and recur.
    • Resection is often not curative, and postoperative mortality is high.
• Secondary Tumours:
  • Generally managed as part of the overall treatment of the primary malignancy, with palliative care measures due to their poor prognosis.

3.7 Long-Term Management

• Follow-Up:
  • Benign Tumours:
    • After surgical excision, regular follow-up is advised to monitor for recurrence, although recurrence is rare.
  • Malignant and Secondary Tumours:
    • Long-term management is palliative and focuses on symptom control and maintaining quality of life.
• Multidisciplinary Approach:
  • Involvement of cardiology, cardiothoracic surgery, oncology, and palliative care teams is essential for the management of malignant and metastatic cardiac tumours.

3.8 Complications

• For Benign Tumours:
  • Local effects such as obstruction of the valve (e.g. mitral valve) causing syncope or heart failure.
  • Embolisation of tumour fragments can cause systemic emboli.
• For Malignant Tumours:
  • Rapid local invasion and metastasis, with a high likelihood of recurrence even after surgical removal.
• Secondary Tumours:
  • Due to metastatic spread, complications are related to the primary cancer and often result in poor outcomes.