Pericardial Disease and Tamponade

Pericardial disease runs from a self-limited inflammation to a rapidly fatal squeeze on the heart. The key is recognizing acute pericarditis correctly and never missing the moment an effusion becomes tamponade — a preload-dependent emergency where the wrong reflex (diuresis) is dangerous.

• •Diagnose with ≥2 of 4: characteristic pleuritic chest pain (better sitting up/leaning forward, worse supine, may radiate to the trapezius ridge), a pericardial friction rub, suggestive EKG changes, or a new/worsening pericardial effusion.
• •EKG classically shows diffuse (widespread) ST elevation with PR depression — distinct from the regional ST elevation of STEMI.
• •The EKG evolves through stages: (1) diffuse ST elevation / PR depression → (2) normalization → (3) widespread T-wave inversion → (4) resolution.
• •Causes: viral/idiopathic (most common), post-MI (including Dressler), uremia, autoimmune, malignancy, post-cardiac-surgery or post-procedure.

Doses are typical adult starting points; confirm against your formulary and the patient’s renal/GI risk.

• •NSAID: ibuprofen 600–800 mg TID (or aspirin 750–1000 mg TID, preferred in the post-MI setting) until symptom-free and CRP normalizes, then taper.
• •Colchicine for ~3 months — weight-based: 0.6 mg once daily if <70 kg, 0.6 mg twice daily if ≥70 kg (US 0.6 mg tablets; the 2015 ESC guideline lists the same regimen as 0.5 mg, the European tablet strength). It cuts recurrence and is the key adjunct.
• •Add a PPI for gastric protection; restrict strenuous exercise until resolved.
• •AVOID corticosteroids as first-line (they raise recurrence) — reserve for specific cases (e.g., autoimmune cause, NSAID contraindication) under specialist guidance.
• •Generally AVOID anticoagulation (hemorrhagic-effusion risk).

• •When troponin rises along with pericarditis, there is myocardial involvement (myopericarditis).
• •Get an echo for ventricular function, restrict exercise, and involve cardiology; the prognosis is usually good but it changes monitoring and follow-up.

• •A pericardial effusion causes tamponade when pressure rises enough to impair cardiac filling — speed of accumulation matters as much as size (a rapid small effusion can tamponade).
• •Output falls because the heart can’t fill — this is obstructive shock physiology.

• •Beck’s triad: hypotension, distended neck veins (elevated JVP), and muffled heart sounds.
• •Pulsus paradoxus: an exaggerated (>10 mmHg) inspiratory fall in systolic BP — it reflects exaggerated ventricular interdependence (inspiration fills the RV, which bows into the LV in the fixed pericardial space); expect sinus tachycardia.
• •EKG: low voltage and/or electrical alternans.
• •Echo: an effusion with early RIGHT-atrial systolic collapse and RIGHT-ventricular diastolic collapse, a plethoric non-collapsing IVC, and exaggerated respiratory variation in mitral/tricuspid inflow.

• •Definitive treatment is drainage — pericardiocentesis (or surgical window), performed by the physician/specialist.
• •Temporize with IV fluids to support preload while arranging drainage.
• •Do NOT diurese or aggressively vasodilate — tamponade is preload-dependent, and dropping preload can precipitate arrest.
• •Avoid intubation/positive-pressure ventilation if you can — it drops preload and can precipitate arrest; if it’s unavoidable, resuscitate and be ready to drain first.

• •A scarred, rigid pericardium limits filling → right-heart failure signs (peripheral edema, ascites, elevated JVP).
• •Clues: a pericardial knock, Kussmaul’s sign (JVP rises with inspiration), and a “septal bounce” on echo.
• •It’s a chronic process, not the acute emergency tamponade is — but worth recognizing as a cause of right-sided failure.

• •Mistaking the diffuse ST elevation of pericarditis for a STEMI (or vice versa).
• •Reaching for corticosteroids first-line (higher recurrence) instead of NSAID + colchicine.
• •Diuresing a hypotensive tamponade patient (worsens filling).
• •Intubating a tamponade patient without resuscitating/draining first.
• •Anticoagulating acute pericarditis (hemorrhagic effusion risk).
• •Underestimating a small but rapidly accumulating effusion.