Pericardial Disease — Viva

Q1: Acute pericarditis — diagnosis and first-line management (2 min)

Examiner: A 24-year-old man presents with sharp pleuritic chest pain, worse lying flat, relieved sitting forward, a three-component friction rub, and ECG showing diffuse concave ST elevation with PR depression. What is your diagnosis, what criteria did you apply, and what is your first-line drug treatment with doses? ^[1][2]

Expected answer: Acute idiopathic (likely viral) pericarditis. ESC 2015 criteria: at least 2 of 4 — chest pain, pericardial rub, ECG changes (diffuse ST elevation/PR depression), new/worsening effusion.^[1][2] Treat with aspirin 750 to 1000 mg PO TID or ibuprofen 600 to 800 mg PO TID for 1 to 2 weeks then taper, plus colchicine 0.5 mg PO BD (if over 70 kg) for 3 months, plus PPI.^[1][8] Activity restriction until symptom-free. Steroids NOT first-line (prior corticosteroid use independently predicts further recurrence, odds ratio 2.89 in CORE).^[10]

Q2: Cardiac tamponade — clinical features and emergency management (3 min)

Examiner: A 60-year-old woman with metastatic lung cancer presents with dyspnoea, hypotension (BP 84/60), raised JVP, and muffled heart sounds. What is the diagnosis, what bedside sign will you look for, and what is your immediate management? ^[1][2]

Expected answer: Cardiac tamponade (Beck triad). Bedside: pulsus paradoxus (over 10 mmHg fall in SBP on inspiration). Confirm with urgent echocardiography (RA/RV collapse, IVC plethora, respiratory variation in inflow).^[3][4] Management: oxygen, IV access, 250 to 500 mL crystalloid bolus (500 mL saline over 10 minutes raised cardiac output in about half of tamponade patients in the classic study; those with baseline SBP under 100 mmHg respond best), avoid diuretics/vasodilators/positive-pressure ventilation, and emergency echo-guided pericardiocentesis (subxiphoid approach).^[5][3][6] Send fluid for cytology, cell count, protein, LDH. If recurrent/malignant, surgical drainage (subxiphoid pericardiostomy) with biopsy.^[3]

Q3: Constrictive vs restrictive — the discriminator (2 min)

Examiner: A patient has raised JVP with a deep y descent, hepatomegaly and ascites. How would you distinguish constrictive pericarditis from restrictive cardiomyopathy, and what is the definitive treatment of constriction? ^[1][2]

Expected answer: Constriction: pericardial knock (early diastolic), Kussmaul sign (JVP rises on inspiration), pericardial calcification on CXR/CT, septal bounce on echo, normal or mildly raised BNP. Restriction: apical S3, markedly raised BNP, myocardial LGE on MRI, no calcification. Cardiac MRI/CT is the key discriminator (pericardial thickness over 2 mm with LGE in constriction; note constriction can occur with normal thickness in up to 20 per cent of cases). Definitive treatment of constriction is pericardiectomy.^[16][1][17]

Q4: Tuberculous pericarditis in the Indian context (2 min)

Examiner: A 45-year-old man from a TB-endemic region presents with constitutional symptoms, a large pericardial effusion and tamponade. Pericardial fluid adenosine deaminase is 90 U/L. What is your diagnosis, your treatment regimen with doses, and what adjunct is added? ^[1][2]

Expected answer: Tuberculous pericarditis (a lymphocytic exudate with an elevated adenosine deaminase level supports the diagnosis). Treatment: standard anti-tubercular therapy (RIPE) — rifampicin 10 mg/kg, isoniazid 5 mg/kg, pyrazinamide 25 mg/kg, ethambutol 15 mg/kg daily for 2 months intensive then rifampicin plus isoniazid for 4 months (total 6 months).^[15] Plus adjunctive corticosteroids (prednisolone, 6-week course in IMPI) — significantly less constrictive pericarditis (4.4 vs 7.8 per cent) but a neutral effect on the composite outcome of death, tamponade or constriction (23.8 vs 24.5 per cent), at the price of more cancers; never without anti-TB therapy.^[14] Pericardiocentesis for tamponade; pericardiectomy for established constriction (constriction developed in 7.8 per cent of placebo-treated IMPI patients).^[14][3]

Q5: Pitfalls and pearls (1 min)

Examiner: Give me two classic pitfalls in the management of pericardial disease. ^[1][2]

Expected answer: (1) Giving corticosteroids for first-episode idiopathic pericarditis — prior steroid use independently predicts further recurrence (odds ratio 2.89). (2) Using NSAIDs or steroids in early post-MI pericarditis — impair healing, raise risk of free-wall rupture; use aspirin high-dose only. (3) Misdiagnosing STEMI as pericarditis (or vice versa) — check for reciprocal changes and PR depression. (4) Forgetting TB in the Indian patient with effusion. (5) Anticoagulating a haemorrhagic effusion (post-catheter) — worsens tamponade.^[10][1][2]

References12ShowHide

1. [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. [2]Cremer PC, Klein AL, Imazio M Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review JAMA, 2024.PMID 39235771
3. [3]Adler Y, Ristić AD, Imazio M, et al. Cardiac tamponade Nat Rev Dis Primers, 2023.PMID 37474539
4. [4]Alerhand S, Adrian RJ, Long B, Avila J Pericardial tamponade: A comprehensive emergency medicine and echocardiography review Am J Emerg Med, 2022.PMID 35696801
5. [5]Sagristà-Sauleda J, Angel J, Sambola A, Permanyer-Miralda G Hemodynamic effects of volume expansion in patients with cardiac tamponade Circulation, 2008.PMID 18332261
6. [6]Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years Mayo Clin Proc, 2002.PMID 12004992
7. [8]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
8. [10]Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE trial Arch Intern Med, 2005.PMID 16186468
9. [14]Mayosi BM, Ntsekhe M, Bosch J, et al. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis N Engl J Med, 2014.PMID 25178809
10. [15]Mayosi BM, Burgess LJ, Doubell AF Tuberculous pericarditis Circulation, 2005.PMID 16330703
11. [16]Gillombardo CB, Hoit BD Constrictive pericarditis in the new millennium J Cardiol, 2024.PMID 37714264
12. [17]Tzani A, Doulamis IP, Tzoumas A, et al. Meta-Analysis of Population Characteristics and Outcomes of Patients Undergoing Pericardiectomy for Constrictive Pericarditis Am J Cardiol, 2021.PMID 33539860