Phys Written Answers · cardiovascular
Pericardial Disease — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for pericardial disease management, including problem-list synthesis, investigation interpretation, and integrated management planning across acute pericarditis, tamponade, constriction, and recurrent disease.
6 min readVerification in progress
On this page
Study tools
Target exams
FRACP DCEMRCP Part 2
Prompt
DCE long-case preparation: structured written reasoning for pericardial disease management, including problem-list synthesis, investigation interpretation, and integrated management planning across acute pericarditis, tamponade, constriction, and recurrent disease.
SAQ 1 — Acute Pericarditis Risk Stratification and Management (20 marks, 30 minutes)
Prompt: Outline your integrated management plan for this patient, including risk stratification, investigation strategy, pharmacological management, and follow-up. Justify each decision with reference to evidence. [1]
Model Answer
Problem list (4 marks): [1]
- Acute pericarditis, likely viral aetiology — confirmed by pleuritic positional chest pain, friction rub, and diffuse ST elevation with PR depression (two diagnostic criteria met; ESC/JACC require at least two of four)
- Myopericarditis — mildly elevated troponin (0.12) with preserved biventricular function; no wall motion abnormalities. This does not indicate ischaemia
- High-risk features present — fever over 38 degrees (38.6) AND oral anticoagulation (apixaban) are both ESC/JACC high-risk criteria mandating admission (ESC 2015, PMID 26320112; JACC 2020, PMID 31918837)
- Paroxysmal atrial fibrillation on apixaban — a bleeding risk factor if pericardial inflammation progresses to a haemorrhagic effusion
- Small pericardial effusion — currently not haemodynamically significant but requires monitoring [1]
Risk stratification — this patient MUST be admitted (3 marks): [1]
This patient has two independent high-risk features requiring hospital admission:
- Fever over 38 degrees — suggests possible non-viral or systemic cause; predicts a more complicated course and higher recurrence risk
- Oral anticoagulation (apixaban) — risk of haemopericardium if pericardial inflammation progresses; also a specific ESC/JACC high-risk criterion [1]
Other ESC/JACC high-risk features to screen for (absent here): large effusion over 2 cm, cardiac tamponade, immunosuppression, trauma, subacute onset, failure of initial outpatient NSAID therapy at one week. [1]
Investigation strategy (4 marks): [1]
| Investigation | Rationale |
|---|---|
| Serial ECG and troponin | Monitor for evolution and myocardial involvement; troponin expected to trend down |
| Repeat echocardiogram at 48 to 72 hours | Monitor effusion size; currently small (0.8 cm) but at risk of expansion on anticoagulation |
| Bloods: FBE, CRP, ESR, U&E, creatinine, LFTs, TFTs | CRP guides treatment response; exclude uraemic and hypothyroid causes; baseline renal function for NSAID use |
| ANA, rheumatoid factor, anti-dsDNA | Screen for autoimmune disease given recurrent-risk profile; send now to avoid needing it later |
| Blood cultures, viral serology (enterovirus, parvovirus B19), HIV test | Given fever; HIV is a specific ESC recommendation |
| Chest X-ray | Baseline; look for pneumonia, TB, malignancy, cardiomegaly |
| Coagulation profile | Baseline before continuing apixaban; assess bleeding risk |
Pharmacological management (6 marks): [1]
| Drug | Dose and duration | Rationale |
|---|---|---|
| Aspirin | 750 to 1000 mg three times daily for 1 to 2 weeks, then taper over 2 to 4 weeks guided by symptom resolution and CRP normalisation | First-line NSAID for acute pericarditis. In a patient on apixaban, any NSAID needs individualised bleeding-risk assessment with cardiology input — there is no clearly safe choice, so keep the course as short as possible, add PPI gastroprotection, and lean on colchicine. |
| Colchicine | 0.5 mg twice daily for 3 months (patient is likely over 70 kg) | ICAP trial (PMID 23992557) — halves recurrence rate (16.7% vs 37.5%). Do NOT load; main side effect is diarrhoea, reduce to 0.5 mg daily if it occurs. Colchicine is safe with apixaban (no major interaction). |
| PPI gastroprotection | Pantoprazole 40 mg daily | Essential with NSAID plus apixaban — high gastrointestinal bleeding risk |
| Anticoagulation decision | Hold apixaban temporarily while febrile and with an active effusion; reassess once pericarditis resolves and effusion is stable or resolved | The combination of active pericardial inflammation (risk of haemopericardium) plus NSAID plus apixaban creates a dangerous bleeding risk. The ESC guidelines list oral anticoagulation as a high-risk feature precisely because of this. Discuss with cardiology; short interruption of apixaban usually needs no heparin bridging. |
| Avoid corticosteroids | Not indicated | Corticosteroids are NOT first-line for viral pericarditis — they increase recurrence up to four-fold (JACC 2020, PMID 31918837). Reserved for NSAID failure, autoimmune disease, or uraemic pericarditis. |
Activity restriction and follow-up (3 marks): [1]
- Restrict strenuous physical activity and competitive sport until symptom-free and CRP normalised — typically 3 months for competitive athletes (ESC 2015).
- Repeat echocardiogram at 1 week to ensure effusion is not expanding, and at completion of the aspirin course.
- Follow-up in physician or cardiology clinic at 1 week to review symptom response, CRP trend, and effusion size.
- Patient education — explain that pericarditis usually resolves fully but recurs in 15 to 30% of cases; advise that early return of symptoms should prompt urgent review.
- NSAID and colchicine weaning plan — taper aspirin over 2 to 4 weeks after CRP normalises; continue colchicine for the full 3 months regardless of symptom resolution. [1]
References3ShowHide
- [1]Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases Eur Heart J, 2015.PMID 26320112
- [2]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
- [3]Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review J Am Coll Cardiol, 2020.PMID 31918837