Pericarditis – One-Liner Case Traps
Pericarditis – One-Liner Case Traps
- Diffuse concave ST elevation with PR depression but normal troponin → Acute pericarditis, not STEMI
- Troponin rise with preserved LV function in pericarditis → Myopericarditis
- Chest pain 48 hours after MI with diffuse ST elevation → Early post-MI pericarditis
- Fever, pericardial effusion 6 weeks post-MI → Dressler syndrome
- Post-MI pericarditis drug of choice → High-dose aspirin
- Diffuse ST elevation with reciprocal depression → Not pericarditis
- ST/T ratio in V6 >0.25 → Pericarditis over early repolarization
- Large painless pericardial effusion in CKD → Uremic pericarditis
- Hemorrhagic pericardial effusion → Malignancy until proven otherwise
- Raised JVP, hypotension, clear lungs → Cardiac tamponade
- Earliest echo sign of tamponade → RA systolic collapse
- Pulsus paradoxus >10 mmHg → Tamponade physiology
- Sudden hypotension in moderate effusion after cough → Acute tamponade
- Diuretics in tamponade → Worsens shock
- Persistent high JVP after pericardiocentesis → Effusive-constrictive pericarditis
- TB pericarditis with ascites and normal BNP → Constrictive pericarditis
- Kussmaul sign with normal LV systolic function → Constrictive pericarditis
- Elevated BNP favors → Restrictive cardiomyopathy, not constriction
- Definitive treatment of constrictive pericarditis → Pericardiectomy
- Septal bounce on echo → Constrictive physiology
- Recurrent chest pain after steroid taper → Steroid-dependent pericarditis
- Most important cytokine in recurrent pericarditis → IL-1
- Colchicine-resistant recurrent pericarditis → Anakinra indicated
- Early steroid use in viral pericarditis → Increases recurrence risk
- CRP elevated despite symptom resolution → Continue therapy
- CRP-guided taper prevents → Recurrence
- Exercise during acute pericarditis → Triggers relapse/myocarditis
- Pericarditis + AF started on anticoagulation → Risk of hemopericardium
- Sudden shock after anticoagulation → Hemorrhagic tamponade
- Mild troponin rise in pericarditis → Not indication for cath
- PR depression in aVR with PR elevation elsewhere → Pericarditis ECG pattern
- Absence of Q waves in ST elevation → Against STEMI
- Concave ST elevation in all leads → Pericarditis
- Pericardial LGE on CMR → Active inflammation
- Absence of LGE with thickened pericardium → Chronic constriction
- CT showing pericardial calcification → Chronic constrictive disease
- Low-voltage ECG with large effusion → Electrical alternans possible
- Electrical alternans → Large swinging effusion
- Tamponade with preserved BP → Compensated phase
- Narrow pulse pressure in tamponade → Reduced stroke volume
- Pericarditis in pregnancy safest drug → Aspirin (± colchicine selectively)
- Indomethacin in elderly CAD patient → Avoid
- HIV patient with pericarditis → TB or malignancy likely
- Rapidly accumulating small effusion → More dangerous than large slow effusion
- Fever >38°C in pericarditis → High-risk etiology
- Subacute presentation weeks → TB or autoimmune
- Normal echo but classic pain + ECG → Still pericarditis
- Myocarditis vs myopericarditis key difference → LV dysfunction
- Normal BNP in severe right heart failure → Think constriction
- NSAID + colchicine failure + steroid dependence → IL-1 blockade
Pericarditis – 50 Ultra-Hard FAQs (NEET-SS)
1.
Why does PR depression occur in acute pericarditis but not in STEMI?
Answer: Due to atrial epicardial injury causing atrial current of injury; STEMI spares atrial myocardium.
2.
Which ECG lead is most sensitive for early pericarditis?
Answer: Lead II and lateral precordial leads for PR depression.
3.
Why is ST elevation in pericarditis concave upward?
Answer: Due to diffuse subepicardial inflammation rather than transmural ischemia.
4.
What ECG feature best differentiates pericarditis from early repolarization?
Answer: Presence of PR depression and ST/T ratio >0.25 in V6.
5.
Why are troponins elevated in myopericarditis but prognosis remains good?
Answer: Injury is superficial, patchy, and non-necrotic.
6.
Which imaging modality best detects active pericardial inflammation?
Answer: CMR with T2 edema and late gadolinium enhancement.
7.
Why is CRP preferred over ESR for monitoring treatment response?
Answer: CRP correlates better with ongoing inflammation and recurrence risk.
8.
What is the strongest predictor of recurrent pericarditis?
Answer: Early corticosteroid use.
9.
Why should steroids be avoided as first-line therapy?
Answer: They suppress viral clearance and increase recurrence.
10.
What colchicine dose adjustment is required in renal dysfunction?
Answer: Reduce dose by 50% if eGFR <30 mL/min.
11.
Why is colchicine contraindicated with clarithromycin?
Answer: CYP3A4 inhibition → fatal colchicine toxicity.
12.
Why is aspirin preferred over NSAIDs post-MI pericarditis?
Answer: NSAIDs impair myocardial healing; aspirin does not.
13.
What defines incessant pericarditis?
Answer: Symptoms persisting >4 weeks but <3 months without remission.
14.
Why is exercise restriction mandatory in acute pericarditis?
Answer: Physical stress increases inflammatory cytokines and recurrence.
15.
Which pericarditis etiology mandates immediate pericardiocentesis?
Answer: Purulent (bacterial) pericarditis.
16.
Why is TB pericarditis associated with high constriction risk?
Answer: Granulomatous fibrosis causes pericardial thickening and calcification.
17.
Which finding best predicts progression to constrictive pericarditis?
Answer: Persistent pericardial LGE on CMR.
18.
Why can BNP be normal in constrictive pericarditis?
Answer: Myocardial stretch is limited by rigid pericardium.
19.
What echocardiographic sign indicates effusive-constrictive pericarditis?
Answer: Persistently elevated JVP after pericardiocentesis.
20.
Why is pulsus paradoxus absent in chronic constriction?
Answer: Fixed intrapericardial constraint prevents respiratory variation.
21.
Which echo Doppler parameter is most specific for constriction?
Answer: Respiratory variation in mitral inflow >25%.
22.
Why does hepatic vein diastolic flow reversal occur in constriction?
Answer: Enhanced ventricular interdependence during expiration.
23.
Why is CT superior to echo for pericardial calcification?
Answer: High spatial resolution for calcium detection.
24.
Which drug class is emerging for steroid-dependent recurrent pericarditis?
Answer: IL-1 inhibitors (Anakinra, Rilonacept).
25.
What trial established colchicine benefit in first-episode pericarditis?
Answer: ICAP trial.
26.
Why is Rilonacept superior to steroids in recurrence prevention?
Answer: Targets IL-1–mediated autoinflammatory pathway.
27.
Which pericarditis subtype is most likely autoimmune?
Answer: Recurrent idiopathic pericarditis.
28.
Why is pericardial biopsy rarely diagnostic?
Answer: Low yield unless malignancy or TB suspected.
29.
Which malignancy most commonly causes pericardial effusion?
Answer: Lung cancer.
30.
Why does hypothyroidism cause large effusions without tamponade?
Answer: Slow accumulation allows pericardial stretch.
31.
Which effusion is classically hemorrhagic?
Answer: Malignancy or tuberculosis.
32.
Why is Beck’s triad unreliable in subacute tamponade?
Answer: Compensatory mechanisms blunt classic signs.
33.
What echo sign indicates early tamponade?
Answer: Right atrial systolic collapse.
34.
Why does tamponade equalize diastolic pressures?
Answer: Uniform pericardial pressure limits chamber filling.
35.
Which pericarditis requires mandatory hospitalization?
Answer: Fever >38°C, large effusion, immunosuppression, trauma, or myopericarditis.
36.
Why are anticoagulants avoided in acute pericarditis?
Answer: Risk of hemorrhagic effusion.
37.
What differentiates myopericarditis from perimyocarditis?
Answer: Predominant pericardial vs myocardial involvement.
38.
Which viral cause is linked with severe myocarditis overlap?
Answer: Coxsackie B virus.
39.
Why is pericardial knock absent in effusion?
Answer: Fluid dampens sudden cessation of ventricular filling.
40.
What is Dressler syndrome mediated by?
Answer: Autoimmune response to myocardial antigens.
41.
Why does Dressler occur weeks after MI?
Answer: Time required for antibody formation.
42.
Which lab abnormality suggests bacterial pericarditis?
Answer: Very high procalcitonin.
43.
Why is NSAID failure a red flag?
Answer: Suggests non-viral etiology.
44.
Which echo view best detects posterior effusion?
Answer: Parasternal long-axis.
45.
Why does constriction show discordant LV/RV pressure changes?
Answer: Ventricular interdependence with fixed total volume.
46.
What hemodynamic feature distinguishes constriction from restrictive cardiomyopathy?
Answer: Respiratory variation in ventricular filling.
47.
Why is pericardiectomy delayed in active inflammation?
Answer: High surgical mortality and poor outcomes.
48.
Which drug reduces recurrence duration but not mortality?
Answer: Colchicine.
49.
Why is low-dose steroid preferred if unavoidable?
Answer: Reduces rebound inflammation.
50.
What is the single most exam-relevant concept in pericarditis?
Answer: Differentiation from STEMI using ECG + clinical context.
