Pericarditis – Core Concepts
Pericarditis – Core Concepts
Definition
Inflammation of the pericardial sac, which may be acute, incessant, recurrent, or chronic constrictive.
Etiology
Most common: Idiopathic (presumed viral)
Others
- Viral: Coxsackie, Echovirus, Influenza, HIV
- Bacterial: Tuberculosis (important in India), pyogenic
- Post-MI: Early (fibrinous), Dressler syndrome
- Autoimmune: SLE, RA
- Uremia
- Malignancy
- Radiation
- Drugs: Hydralazine, procainamide, isoniazid
Clinical Features
- Chest pain: Sharp, pleuritic, worse supine, relieved by sitting forward
- Pericardial friction rub: Triphasic, scratchy, transient
- Dyspnea
- Low-grade fever
ECG Changes (Acute Pericarditis)
Classical 4 stages
- Diffuse concave ST elevation + PR depression
- ST normalization
- T-wave inversion
- ECG normalization
Key distinctions from STEMI
- No reciprocal ST depression (except aVR, V1)
- PR depression is characteristic
- ST/T ratio in V6 > 0.25 favors pericarditis
Investigations
- Inflammatory markers: ↑ CRP, ESR
- Troponin: Mildly elevated if myopericarditis
- Echocardiography: Effusion, tamponade physiology
- Cardiac MRI: Pericardial edema, late gadolinium enhancement
- CT: Pericardial thickening/calcification (chronic disease)
Diagnostic Criteria (≥2 required)
- Typical chest pain
- Pericardial rub
- Typical ECG changes
- New or worsening pericardial effusion
Management (Acute Pericarditis)
First-line
- NSAIDs
- Ibuprofen 600–800 mg TDS
- Aspirin preferred post-MI
- Colchicine
- 0.5 mg BD (≥70 kg)
- Duration: 3 months (acute), 6 months (recurrent)
Avoid
- Steroids unless refractory, autoimmune, or contraindications to NSAIDs
(Increase recurrence risk)
High-Risk Features (Require Admission)
- Fever >38°C
- Subacute onset
- Large effusion
- Cardiac tamponade
- Immunosuppression
- Trauma
- Failure to respond to NSAIDs
Complications
- Pericardial effusion
- Cardiac tamponade
- Recurrent pericarditis
- Constrictive pericarditis
Special Notes
- TB pericarditis: Think in chronic effusion, constriction; treat with ATT ± steroids
- Myopericarditis: Troponin rise, LV dysfunction → activity restriction mandatory
1. The most common cause of acute pericarditis is:
A. Tuberculosis
B. Malignancy
C. Idiopathic (viral)
D. Autoimmune disease
Most cases are idiopathic, presumed viral in origin.
2. Chest pain of acute pericarditis typically:
A. Worsens on exertion
B. Worsens in supine position
C. Improves with nitrates
D. Is pressure-like
Pain is pleuritic and positional, relieved by sitting forward.
3. Most specific physical sign of acute pericarditis:
A. Pulsus paradoxus
B. Raised JVP
C. Pericardial friction rub
D. Loud P2
A scratchy, triphasic pericardial rub is highly specific.
4. Characteristic ECG feature of acute pericarditis:
A. Convex ST elevation
B. PR depression
C. Pathological Q waves
D. Reciprocal ST depression
PR depression is classic due to atrial involvement.
5. ECG ST elevation in pericarditis is typically:
A. Regional
B. Convex
C. Diffuse and concave
D. With Q waves
Diffuse concave ST elevation differentiates from STEMI.
6. ST/T ratio in V6 >0.25 suggests:
A. Early repolarization
B. Acute pericarditis
C. STEMI
D. LVH
ST/T ratio >0.25 favors pericarditis.
7. How many criteria are required to diagnose acute pericarditis?
A. One
B. Two
C. Three
D. Four
Diagnosis requires ≥2 of 4 standard criteria.
8. All are diagnostic criteria EXCEPT:
A. Typical chest pain
B. Pericardial rub
C. ECG changes
D. Raised troponin
Troponin rise suggests myopericarditis, not diagnostic.
9. First-line treatment of acute pericarditis:
A. Steroids
B. NSAIDs + colchicine
C. Antibiotics
D. Beta blockers
NSAIDs plus colchicine reduce recurrence.
10. Colchicine duration in acute pericarditis:
A. 2 weeks
B. 1 month
C. 3 months
D. 12 months
Three months is recommended for first episode.
11. Steroids in pericarditis increase risk of:
A. Tamponade
B. Recurrence
C. Arrhythmias
D. Constriction
Steroids increase recurrence unless specifically indicated.
12. Which pericarditis etiology most commonly leads to constriction?
A. Viral
B. Tuberculosis
C. Post-MI
D. Uremia
TB pericarditis has the highest risk of chronic constriction.
13. Dressler syndrome is best described as:
A. Early fibrinous pericarditis
B. Ischemic myocarditis
C. Autoimmune post-MI pericarditis
D. Infective endocarditis
Dressler is an autoimmune pericarditis occurring weeks after MI.
14. Which ECG lead typically shows reciprocal ST depression in pericarditis?
A. II
B. III
C. aVL
D. aVR
Only aVR (and sometimes V1) show ST depression.
15. PR elevation in lead aVR suggests:
A. STEMI
B. Acute pericarditis
C. Early repolarization
D. Hyperkalemia
PR elevation in aVR is reciprocal to PR depression elsewhere.
16. Raised troponin in pericarditis indicates:
A. STEMI
B. Poor prognosis
C. Myopericarditis
D. Tamponade
Troponin rise indicates myocardial involvement.
17. Most sensitive imaging modality for pericardial inflammation:
A. Echo
B. CT
C. Cardiac MRI
D. Chest X-ray
CMR detects edema and LGE with high sensitivity.
18. Which is NOT a high-risk feature requiring admission?
A. Fever >38°C
B. Large effusion
C. Immunosuppression
D. Typical viral prodrome
Typical viral pericarditis without risk features can be outpatient.
19. NSAID of choice post-MI pericarditis:
A. Ibuprofen
B. Indomethacin
C. Aspirin
D. Naproxen
Aspirin is preferred post-MI; other NSAIDs interfere with healing.
20. Colchicine reduces recurrence by inhibiting:
A. COX enzymes
B. Microtubule polymerization
C. Platelet aggregation
D. RAAS
Colchicine blocks neutrophil migration via microtubules.
21. Pulsus paradoxus is most suggestive of:
A. Constrictive pericarditis
B. Restrictive cardiomyopathy
C. Cardiac tamponade
D. Myocarditis
Inspiratory fall in SBP >10 mmHg is classic for tamponade.
22. Beck triad includes all EXCEPT:
A. Hypotension
B. Raised JVP
C. Muffled heart sounds
D. Bradycardia
Beck triad does not include bradycardia.
23. Most common cause of recurrent pericarditis:
A. TB
B. Idiopathic/immune-mediated
C. Malignancy
D. Uremia
Most recurrences are immune-mediated.
24. Recurrent pericarditis is defined as recurrence after:
A. 48 hours
B. 1 week
C. 4–6 weeks symptom-free interval
D. 6 months
A symptom-free interval of at least 4–6 weeks is required.
25. Best next step in hemodynamically unstable tamponade:
A. IV diuretics
B. Emergency pericardiocentesis
C. NSAIDs
D. Steroids
Tamponade with instability is a medical emergency.
26. Kussmaul sign is classically seen in:
A. Tamponade
B. Acute pericarditis
C. Constrictive pericarditis
D. Dilated cardiomyopathy
Paradoxical rise in JVP on inspiration suggests constriction.
27. Pericardial knock occurs in:
A. Tamponade
B. Constrictive pericarditis
C. Myocarditis
D. Acute MI
Early diastolic knock is due to abrupt cessation of filling.
28. Square root sign on ventricular pressure tracing indicates:
A. Restrictive cardiomyopathy
B. Tamponade
C. Constrictive pericarditis
D. DCM
Rapid early filling with abrupt halt is typical of constriction.
29. Echo finding favoring tamponade over constriction:
A. Septal bounce
B. RA/RV diastolic collapse
C. Respiratory ventricular interdependence
D. Thick pericardium
Chamber collapse is classic for tamponade.
30. TB pericarditis treatment includes:
A. NSAIDs only
B. Steroids alone
C. ATT ± steroids
D. Surgery only
Anti-tubercular therapy is essential; steroids reduce inflammation.
31. Pericardial calcification is best detected by:
A. Echo
B. CT scan
C. MRI
D. ECG
CT is superior for detecting calcification.
32. Which drug is contraindicated in uremic pericarditis?
A. Colchicine
B. Dialysis
C. NSAIDs
D. Steroids
NSAIDs worsen renal dysfunction in uremia.
33. Mainstay of uremic pericarditis management:
A. Steroids
B. Intensive dialysis
C. NSAIDs
D. Surgery
Dialysis treats the underlying cause.
34. Malignant pericardial effusion most commonly presents with:
A. Fever
B. Acute pain
C. Tamponade
D. Constriction
Malignant effusions accumulate rapidly causing tamponade.
35. Which malignancy most commonly causes pericardial effusion?
A. Lung cancer
B. Colon cancer
C. Prostate cancer
D. Thyroid cancer
Lung cancer is the commonest cause of malignant effusion.
36. Which finding differentiates constriction from restriction?
A. Elevated BNP
B. Biatrial enlargement
C. Respiratory ventricular interdependence
D. Diastolic dysfunction
Marked ventricular interdependence favors constriction.
37. BNP levels in constrictive pericarditis are usually:
A. Very high
B. Normal or mildly elevated
C. Diagnostic
D. Always low
BNP is lower than in restrictive cardiomyopathy.
38. Surgical treatment for constrictive pericarditis:
A. Pericardiocentesis
B. Window formation
C. Pericardiectomy
D. CABG
Complete pericardiectomy is definitive treatment.
39. Early complication of acute pericarditis:
A. Calcification
B. Effusion
C. Constriction
D. HFpEF
Effusion develops early due to inflammation.
40. Most common ECG stage at presentation:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Patients usually present in Stage I.
41. Activity restriction in myopericarditis should be for:
A. 2 weeks
B. 1 month
C. 3–6 months
D. Life-long
Exercise restriction reduces arrhythmic risk.
42. Most common viral cause:
A. Adenovirus
B. Coxsackie virus
C. EBV
D. CMV
Coxsackie B is classically implicated.
43. Low voltage ECG suggests:
A. Acute pericarditis
B. Myocarditis
C. Large pericardial effusion
D. LVH
Electrical dampening occurs with large effusions.
44. Electrical alternans indicates:
A. STEMI
B. Cardiac tamponade
C. Atrial flutter
D. VT
Beat-to-beat QRS variation suggests swinging heart.
45. Most important prognostic factor in acute pericarditis:
A. Chest pain severity
B. ECG stage
C. Etiology
D. Effusion size
Specific causes (TB, malignancy) determine prognosis.
46. Which pericarditis has minimal ECG changes?
A. Viral
B. Uremic
C. Post-MI
D. TB
Uremic pericarditis often lacks classic ECG changes.
47. Preferred steroid if absolutely needed:
A. Dexamethasone
B. Hydrocortisone
C. Low-dose prednisolone
D. Methylprednisolone pulse
Low-dose steroids reduce recurrence risk.
48. Pericardial window is indicated for:
A. Acute viral pericarditis
B. Recurrent malignant effusion
C. Dressler syndrome
D. Uremic pericarditis
Window prevents re-accumulation in malignancy.
49. Effusive–constrictive pericarditis implies:
A. Restrictive cardiomyopathy
B. Pure effusion
C. Persistent constriction after drainage
D. Myocarditis
Constrictive physiology persists despite effusion removal.
50. Which sign suggests chronicity?
A. Chest pain
B. Fever
C. PR depression
D. Hepatomegaly
Systemic venous congestion suggests chronic constriction.
51. Pericardial thickening >4 mm is best measured by:
A. ECG
B. CT / MRI
C. Echo
D. X-ray
Cross-sectional imaging is required.
52. Typical echo feature of constriction:
A. Global hypokinesia
B. Dilated LV
C. Septal bounce
D. Apical thrombus
Septal bounce reflects ventricular interdependence.
53. Pericarditis following cardiac surgery is termed:
A. Viral pericarditis
B. Post-pericardiotomy syndrome
C. Dressler syndrome
D. Uremic pericarditis
Autoimmune reaction after surgery.
54. Most common symptom of constrictive pericarditis:
A. Chest pain
B. Syncope
C. Right heart failure
D. Palpitations
Systemic venous congestion dominates.
55. Which lab marker tracks disease activity best?
A. Troponin
B. CRP
C. BNP
D. CK-MB
CRP guides therapy duration.
56. Taper NSAIDs when:
A. Pain improves
B. ECG normalizes
C. CRP normalizes
D. Effusion resolves
CRP normalization indicates resolution.
57. Most common complication of recurrent pericarditis:
A. Tamponade
B. Steroid dependence
C. Arrhythmia
D. MI
Repeated relapses lead to steroid dependence.
58. IL-1 blockers (anakinra) are used in:
A. Acute viral pericarditis
B. TB pericarditis
C. Refractory recurrent pericarditis
D. Uremic pericarditis
IL-1 blockade targets autoinflammatory mechanisms.
59. Which feature favors early repolarization over pericarditis?
A. Diffuse ST elevation
B. Chest pain
C. No PR depression
D. Raised CRP
PR depression is absent in early repolarization.
60. Overall prognosis of idiopathic acute pericarditis is:
A. Poor
B. Guarded
C. Variable
D. Excellent
Idiopathic/viral pericarditis has excellent prognosis.
