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Investigations for Pericarditis

Diagnosing pericarditis involves a combination of clinical assessment, specific tests to confirm inflammation, identify the cause, and assess for complications.

• History: Detailed inquiry about chest pain characteristics (onset, location, radiation, aggravating/relieving factors), fever, recent infections, autoimmune conditions, trauma, medications, and travel history.
• Physical Exam:
  • Pericardial Friction Rub: The hallmark sign, a scratching or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border, with the patient leaning forward and holding their breath in expiration.
  • Signs of Pericardial Effusion/Tamponade: Muffled heart sounds, pulsus paradoxus, jugular venous distension, hypotension (late signs).
  • Signs of Systemic Disease: Rash, joint swelling (suggesting autoimmune disease).

• Classic Findings: Widespread ST-segment elevation (concave upwards) in most leads (unlike MI, which is localized and convex), and PR-segment depression (especially in leads II, aVF, V5, V6). These changes reflect inflammation of the epicardium.
• Evolution: ECG changes typically evolve over days to weeks, from ST elevation to T-wave inversion, then normalization.

• Purpose: The most important imaging test. It is essential for assessing for pericardial effusion (fluid around the heart) and its hemodynamic significance (e.g., signs of cardiac tamponade).
• Information Provided: Can visualize the pericardium, quantify effusion size, assess cardiac chamber size and function, and identify signs of cardiac tamponade (e.g., right ventricular diastolic collapse, paradoxical septal motion).

• Cardiac Computed Tomography (CT): Useful for visualizing pericardial thickening, calcification (in constrictive pericarditis), and large effusions. Can help differentiate pericardial disease from myocardial disease.
• Cardiovascular Magnetic Resonance Imaging (MRI): Provides excellent soft tissue characterization. It is the gold standard for detecting pericardial inflammation, edema, and fibrosis. Can also differentiate constrictive pericarditis from restrictive cardiomyopathy.

• Inflammatory Markers:
  • C-reactive protein (CRP): Usually elevated and helps confirm inflammation. Serial CRP levels can monitor disease activity and response to treatment.
  • Erythrocyte Sedimentation Rate (ESR): Also typically elevated, another general marker of inflammation.
• Cardiac Biomarkers:
  • Troponin (I or T): May be mildly elevated in pericarditis if there is associated myocardial inflammation (myopericarditis), indicating some degree of myocardial cell injury. Higher levels raise suspicion for myocarditis or myocardial infarction.
  • CK-MB and Myoglobin: Less specific than troponin for cardiac injury, but may be checked.
• Infectious Workup: Depending on clinical suspicion, tests for specific pathogens:
  • Viral Serology: (e.g., Coxsackievirus antibodies) may be done but often not helpful for acute management.
  • Bacterial Cultures: Blood cultures if sepsis is suspected. Pericardial fluid culture if pericardiocentesis is performed.
  • TB Tests: Tuberculin skin test (PPD), interferon-gamma release assays (IGRAs), and acid-fast bacilli (AFB) stains/cultures on pericardial fluid.
• Autoimmune Markers:
  • Antinuclear Antibodies (ANA), Rheumatoid Factor (RF), Anti-dsDNA: If autoimmune disease is suspected.
• Renal Function Tests:
  • Blood Urea Nitrogen (BUN) and Creatinine: To assess for uremia in patients with kidney disease.

Nursing Interventions and Management of Pericarditis

Nursing care for patients with pericarditis focuses on pain management, monitoring for complications, providing emotional support, and patient education.

General Principles of Management

• Goal: Relieve pain, reduce inflammation, prevent complications (e.g., cardiac tamponade, constrictive pericarditis), and treat the underlying cause.
• Setting: Mild cases may be managed outpatient, while moderate to severe cases, or those with complications, require hospitalization.

Management for Mild Pericarditis

Patients with mild, uncomplicated pericarditis often respond well to conservative measures and oral medications.

• Assess Patient’s Pain: Characterize the pain (sharp, stabbing, dull), location, radiation, and aggravating/relieving factors. Use a pain scale (e.g., 0-10) to quantify severity. Pericarditis pain can be excruciatingly painful.
• Positioning for Pain Relief: Keep patient in a high Fowler’s position (sitting upright) or encourage leaning forward. Avoid a supine (lying flat) position, as it exacerbates pericardial pain by increasing pressure on the inflamed pericardium.

• Constant Vigilance: Cardiac tamponade is a life-threatening complication that requires immediate recognition and intervention.
• Key Signs to Monitor (Beck's Triad):
  • Muffled or Distant Heart Sounds: Due to fluid buildup around the heart.
  • Jugular Venous Distension (JVD) with Clear Lungs: Increased pressure in the right atrium due to restricted filling, but without pulmonary congestion typical of heart failure.
  • Hypotension: Decreased cardiac output due to compression of the heart.
• Pulsus Paradoxus: A significant (typically >10 mmHg) drop in systolic blood pressure during inspiration. This is a classic sign of cardiac tamponade and severe restrictive filling.
• Tachycardia: The heart attempts to compensate for reduced cardiac output by increasing its rate.
• Other Signs: Narrowed pulse pressure, decreased urine output, cool extremities, altered mental status (signs of decreased perfusion).

• First-line Therapy:
  • High-dose Aspirin: Often used, especially for post-MI pericarditis. It has both anti-inflammatory and anti-platelet effects.
  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): Such as Ibuprofen, Indomethacin. These are the cornerstone of treatment for acute pericarditis.
  • Nursing Considerations: Administer with food or milk to minimize gastrointestinal (GI) upset. Monitor for GI bleeding (e.g., black, tarry stools; coffee-ground emesis). Advise patients to take with a full glass of water.
• Colchicine: An anti-inflammatory agent that works by inhibiting microtubule assembly, reducing inflammation. It is increasingly used as first-line therapy or in combination with NSAIDs, and is particularly effective in preventing recurrence.
  • Nursing Considerations: Do not take with grapefruit juice as it increases colchicine toxicity (nausea, vomiting, abdominal pain, diarrhea). Can be taken with or without food. Monitor for GI side effects.
• Corticosteroids: Such as Prednisone. Reserved for patients who do not respond to NSAIDs/Colchicine, have contraindications to them, or have specific etiologies (e.g., autoimmune).
  • Nursing Considerations: Administer with food. Monitor for side effects (e.g., hyperglycemia, increased infection risk, fluid retention, mood changes). Taper slowly to prevent rebound inflammation.
• IV Antibiotics: Administered if bacterial pericarditis is diagnosed or strongly suspected. Based on culture and sensitivity results.

Management for Moderate to Severe Pericarditis / Hospitalized Patients

These patients require more intensive monitoring and often invasive procedures.

• Establish Good Rapport: Essential for building trust and reducing patient anxiety.
• Detailed History Taking: Include smoking history, anginal pain characteristics (differentiate from pericardial pain), and other presenting symptoms.
• Continuous Observations: Monitor vital signs (temperature, pulse, respiration, blood pressure) frequently. Perform a thorough general examination, including cardiovascular, respiratory, and peripheral assessments.

• Positioning: Continue to keep the patient in high Fowler’s position or encourage leaning forward to relieve pain.
• Pain Level Monitoring: Continuously monitor patient pain level using a standardized scale and evaluate the effectiveness of analgesics within 30 minutes of administration.
• Administer Prescribed Pain Medication: May include stronger analgesics such as morphine or other opioids if NSAIDs are insufficient.

• Monitor for Cardiac Tamponade: Hourly or more frequent assessment for signs of cardiac tamponade (pulsus paradoxus, JVD, muffled heart sounds, hypotension, tachycardia). Notify physician immediately if signs develop.
• Continuous ECG Monitoring: To detect arrhythmias or worsening ST-T changes.

• Careful Maintenance of Fluid Intake and Output (I&O): Essential, especially if there's a risk of fluid overload or if diuretics are used.
• Daily Weight Check: To monitor for fluid retention.
• Administer O2: Maintain SpO2 >90% to optimize oxygen delivery to tissues.
• IV Antihypertensive Medication: If persistent blood pressure elevation is a concern (though hypotension is more common with tamponade).

Complications of Pericarditis

While most cases of acute pericarditis are benign and self-limiting, complications can occur, ranging from mild to life-threatening.

1. Pericardial Effusion:
   • Description: Accumulation of excess fluid within the pericardial sac. It is a common complication.
   • Severity: Can range from small and asymptomatic to large and rapidly accumulating, which can lead to cardiac tamponade.
2. Cardiac Tamponade:
   • Description: A medical emergency where a large or rapidly accumulating pericardial effusion compresses the heart, severely restricting its ability to fill with blood during diastole.
   • Consequences: Leads to a significant decrease in cardiac output, hypotension, and shock if not treated promptly.
   • Treatment: Requires urgent pericardiocentesis (fluid drainage) or surgical drainage.
3. Recurrent Pericarditis:
   • Description: Episodes of pericarditis that recur after a symptom-free interval following an initial acute episode. This can be very distressing for patients.
   • Management: Often requires long-term anti-inflammatory therapy, sometimes with colchicine.
4. Chronic Pericarditis:
   • Description: Pericarditis that persists for more than 3 months. Can lead to thickening and fibrosis of the pericardium.
5. Constrictive Pericarditis:
   • Description: A severe, long-term complication where the pericardium becomes thick, rigid, and fibrotic, preventing the heart from filling properly.
   • Consequences: Leads to symptoms of right-sided heart failure (e.g., severe peripheral edema, ascites, elevated JVD) and can be progressive.
   • Treatment: Often requires surgical pericardiectomy (removal of the pericardium).
6. Myocarditis (Myopericarditis):
   • Description: Inflammation of the heart muscle occurring concurrently with pericarditis.
   • Consequences: Can lead to myocardial dysfunction, arrhythmias, and elevated cardiac biomarkers (e.g., troponin).
7. Fatal Hemorrhage:
   • Context: This is a very rare but catastrophic complication, typically associated with traumatic pericardial injury, iatrogenic injury during procedures (e.g., central line insertion, pericardiocentesis), or rupture of a large vessel (e.g., aortic dissection) into the pericardial sac.
8. Stroke and Paraplegia due to Interruption of the Anterior Spinal Artery, Abdominal Ischemia:
   • Context: These are not direct complications of typical pericarditis. They are severe complications specifically associated with Aortic Dissection, especially if it involves the great vessels originating from the aorta or compromises blood supply to the spinal cord or abdominal organs. If an aortic dissection leads to hemopericardium, it can mimic pericarditis. It's crucial to differentiate these conditions due to the vastly different prognoses and emergency management required for aortic dissection.