🫀 Pericardial disease refers to a spectrum of conditions affecting the pericardium, the fibrous sac surrounding the heart. The pericardium normally provides mechanical protection, prevents overdistension, and maintains smooth diastolic filling. When diseased, it may become inflamed (pericarditis), fill with fluid (effusion, tamponade), or thicken and scar (constriction). 👉 Clinical importance: pericardial pathology can range from mild chest pain to rapid cardiovascular collapse, making recognition and urgent management essential.

🔬 Pathophysiology

🔥 Acute Pericarditis: Inflammation leads to vascular leakage, fibrin deposition, and pain due to irritation of parietal pericardium (somatically innervated by phrenic nerves). Viral infections and autoimmune disorders are common causes.
💧 Pericardial Effusion: Fluid accumulates between visceral and parietal layers. Small effusions may be asymptomatic; rapid accumulation (even 200 ml) can impair filling, while slow accumulation (litres) may be tolerated.
🚨 Cardiac Tamponade: Pericardial pressure rises > right atrial/ventricular diastolic pressure → impaired venous return → ↓ stroke volume → obstructive shock. Compensated initially by tachycardia, but quickly life-threatening.
🧱 Constrictive Pericarditis: Chronic pericardial thickening/calcification → rigid encasement of the heart → impaired diastolic filling and systemic venous congestion. Often follows TB, surgery, or radiation therapy.

📊 Forms of Pericardial Disease

Form	Clinical Features	Investigations	Management
🔥 Acute Pericarditis	Sharp, pleuritic chest pain, worse on inspiration/lying flat. Relieved by sitting up/leaning forward. Pericardial friction rub (high-pitched, “sandpaper” sound). Fever, malaise, ± dyspnoea.	ECG: widespread concave ST elevation, PR depression. Echo: exclude effusion. Bloods: ↑ ESR, CRP, ± troponin if myopericarditis.	NSAIDs (ibuprofen, aspirin) first-line. Colchicine to reduce recurrence (now NICE-backed). Steroids only for autoimmune/refractory cases.
💧 Pericardial Effusion	Dull chest pain, breathlessness. Muffled heart sounds, reduced rub. Large effusions → tamponade features.	Echo: confirms presence of fluid. CXR: “water-bottle” silhouette if large. ECG: low voltage QRS, electrical alternans. Pericardiocentesis if diagnostic analysis needed (infection/malignancy).	Small/asymptomatic → monitor. Large/symptomatic → pericardiocentesis. Always treat underlying cause.
🚨 Cardiac Tamponade	Beck’s triad: hypotension, JVP distension, muffled heart sounds. Pulsus paradoxus (↓ SBP >10 mmHg on inspiration). Tachycardia, shock, anxiety, dyspnoea.	Echo: diastolic collapse of RA/RV. ECG: low voltage, electrical alternans. CXR: enlarged cardiac shadow if chronic effusion.	Emergency pericardiocentesis (bedside or guided). IV fluids while preparing for drainage (to maintain preload). Treat cause (malignancy, TB, trauma, infection).
🧱 Constrictive Pericarditis	Chronic dyspnoea, fatigue. Right heart failure signs: ascites, oedema, raised JVP. Kussmaul’s sign (JVP rises with inspiration), pericardial knock.	Echo: pericardial thickening, abnormal diastolic filling. CT/MRI: pericardial calcification. Catheterisation: equalisation of diastolic pressures.	Diuretics for fluid overload (symptomatic relief). Definitive = surgical pericardiectomy (curative but high-risk).

💡 Commentary & Teaching Pearls

🔑 Acute pericarditis vs MI: Pericarditis gives widespread concave ST elevation + PR depression; MI changes are regional and convex.
⚠️ Beware tamponade: Even small effusions can be fatal if they accumulate rapidly (post-trauma, aortic dissection rupture).
🧱 Constrictive pericarditis mimics cirrhosis/heart failure: think pericardium if ascites + raised JVP without pulmonary oedema.
🧪 Always consider TB, especially in patients from high-prevalence regions — still a common cause worldwide.
🏥 In UK hospitals, colchicine + NSAIDs is now standard for acute pericarditis; steroids are a last resort.
📉 Recurrent effusions or unexplained tamponade should raise suspicion for malignancy.

💡 Exam tip: If chest pain is pleuritic, worse lying flat, better leaning forward → think pericarditis. If you hear muffled heart sounds with shock → think tamponade. Always confirm with echocardiography if suspected.

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Pericardial Disease

🔬 Pathophysiology

📊 Forms of Pericardial Disease

💡 Commentary & Teaching Pearls

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