Pericardial Disease — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mrs Margaret Anderson, 64 years old. [1]

Presenting complaint: Three days of progressive dyspnoea at rest, worsening over hours. Woke this morning with severe breathlessness, dizziness on standing, and a squeezing sensation in the chest. Brought by ambulance. [1]

Past history:

• Stage IV non-small cell lung cancer (adenocarcinoma) — diagnosed 8 months ago, on palliative pembrolizumab
• Ex-smoker (40 pack-years, ceased 2 years ago at diagnosis)
• Hypertension
• No prior cardiac history [1]

Current medications:

• Pembrolizumab 200 mg IV every 3 weeks
• Amlodipine 10 mg daily
• Panadeine forte as needed for pain [1]

Examination findings (trainee elicits):

• Conscious, alert, visibly breathless, sitting upright
• Respiratory rate 28, SpO2 90 percent on room air, 95 percent on 6L oxygen
• Heart rate 124 (sinus tachycardia), blood pressure 88/60
• JVP markedly elevated to the angle of the jaw, no obvious waveform detail
• Heart sounds muffled and difficult to hear
• Systolic blood pressure drops by 16 mmHg on normal inspiration (pulsus paradoxus)
• Lungs clear
• Peripheral perfusion poor — cool peripheries, capillary refill 4 seconds
• No peripheral oedema, no ascites [1]

Investigations:

• ECG: sinus tachycardia, low voltage (QRS 4 mm in limb leads), beat-to-beat variation in QRS amplitude (electrical alternans)
• Chest X-ray: markedly enlarged globular cardiac silhouette with clear lung fields
• Point-of-care echocardiogram: large circumferential pericardial effusion (3 cm diastolic separation), right ventricular diastolic collapse, right atrial collapse, IVC plethoric with less than 50 percent collapse on sniff
• Bloods: Hb 112, WCC 9.4, platelets 280, Na 136, K 4.2, creatinine 90, troponin 0.05 (normal), CRP 42 [1]

Candidate's structured presentation (model)

Opening statement: [1]

"Mrs Anderson is a 64-year-old woman with metastatic non-small cell lung cancer on palliative pembrolizumab who presents with acute, life-threatening cardiac tamponade. She has the classic clinical triad — hypotension (BP 88/60), a markedly elevated JVP, and muffled heart sounds (Beck triad) — with pulsus paradoxus of 16 mmHg, and confirmatory echocardiographic findings of a large circumferential effusion with right ventricular diastolic collapse and IVC plethora. [1]

Her main problems are:

1. Cardiac tamponade — a medical emergency requiring immediate pericardiocentesis
2. Metastatic non-small cell lung cancer with likely malignant pericardial effusion
3. Immunotherapy-related pericarditis as a differential for the effusion cause (pembrolizumab can cause immune-related pericarditis)
4. Hypertension (currently masked by the tamponade physiology)
5. Palliative care considerations and prognosis [1]

My immediate priority is emergency pericardiocentesis. This is not a case for further investigation first — the diagnosis is clinical and confirmed by bedside echo, and the treatment is drainage." [1]

Immediate management plan: [1]

1. Emergency pericardiocentesis — echo-guided subxiphoid or apical approach. Alert cardiology, echo, and ICU immediately. Drain until haemodynamics improve. Leave an indwelling pericardial drain for 24 to 48 hours.
2. Call for help — this is a pericardiocentesis that should be performed by an experienced operator under echocardiographic guidance. If cardiology is not immediately available and the patient is deteriorating, perform emergency subxiphoid pericardiocentesis.
3. Temporising measures — give 500 mL crystalloid bolus to maintain preload (this is a bridge to drainage, not a definitive treatment). Avoid vasodilators, diuretics, and positive pressure ventilation, which reduce venous return and can precipitate collapse.
4. Send pericardial fluid — cell count, protein, LDH, glucose, Gram stain and culture, AFB and TB PCR, cytology (to confirm malignancy), and ADA.
5. Address the cause — likely malignant effusion; arrange for a pericardial window (surgical or balloon pericardiotomy) to prevent recurrence once she is stabilised. Consider whether the effusion could be pembrolizumab-induced immune-related pericarditis (send ANA, consider the temporal relationship to the last dose).
6. Oncology and palliative care involvement — the underlying malignancy determines the longer-term prognosis. Malignant pericardial effusion carries a poor prognosis (median survival 2 to 6 months). Discuss goals of care with the patient and family. [1]

Investigation summary: [1]

"The ECG shows low voltage and electrical alternans — the heart is swinging within a large effusion. The chest X-ray shows the classic globular or water-bottle cardiac silhouette with clear lungs. The point-of-care echocardiogram is diagnostic — a large circumferential effusion with right ventricular diastolic collapse (the most specific sign of tamponade), right atrial collapse, and a plethoric IVC. These findings, combined with the clinical Beck triad and pulsus paradoxus, confirm tamponade. The mildly raised CRP and the background of immunotherapy and malignancy are the context for the effusion cause, which will be clarified by pericardial fluid analysis." [1]

Examiner discussion questions

Q: "The patient is hypotensive. Should you start a noradrenaline infusion while waiting for the pericardiocentesis team to arrive?" [1]

"No. The problem is not pump failure — it is obstructed filling. Noradrenaline increases afterload on a heart that cannot fill, and does not address the pericardial compression. The correct temporising measure is a cautious fluid bolus (500 mL crystalloid) to optimise preload, and then urgent drainage. If the patient is in extremis and the pericardiocentesis team cannot arrive immediately, I would perform emergency pericardiocentesis myself. Once the pericardium is drained, the haemodynamics will improve dramatically — this is the definitive treatment." [1]

Q: "Could this be pembrolizumab-induced pericarditis rather than a malignant effusion?" [1]

"Yes, that is an important differential. Immune checkpoint inhibitor therapy (pembrolizumab) can cause immune-related pericarditis and pericardial effusion, typically within the first few months of therapy but occasionally later. The features that would favour immune-related pericarditis include a temporal relationship to the last dose, absence of malignant cells on cytology, an inflammatory fluid profile (high lymphocyte count, high LDH), and response to corticosteroids. However, in a patient with known metastatic lung cancer, a malignant effusion is more likely and must be excluded first by cytology. If cytology is negative and the picture is inflammatory, I would involve the immunotoxicity team and consider holding pembrolizumab and starting corticosteroids for immune-related pericarditis." [1]

Q: "After drainage, the effusion recurs within 48 hours. What is your approach?" [1]

"A recurrent malignant pericardial effusion requires a definitive drainage strategy to prevent repeated tamponade. The options are: surgical pericardial window (subxiphoid pericardiostomy) — creates a permanent pericardial-peritoneal or pericardial-pleural communication; balloon pericardiotomy — a percutaneous technique that creates a pericardial-pleural window; or an indwelling pericardial catheter (PleuroX-type) for intermittent drainage in the palliative setting. The choice depends on the patient's prognosis and performance status. For a patient with metastatic lung cancer and an expected survival of months, a surgical or balloon pericardial window is appropriate. If prognosis is very short (weeks), an indwelling catheter for palliative drainage avoids surgery. This is a decision to make with oncology, palliative care, the patient, and the family." [1]

Q: "How would you discuss the prognosis with the patient?" [1]

"This is a palliative situation and the discussion needs to be honest, compassionate, and patient-centred. I would explain that the cardiac tamponade is a complication of the cancer spreading to the pericardium, that drainage will relieve the immediate life-threatening problem, but that the underlying cancer determines the longer-term outlook. I would involve oncology to discuss whether systemic therapy options remain (the cancer is already on pembrolizumab), and palliative care to address symptom control, advance care planning, and goals. I would ask the patient what is most important to her — time, quality of life, being at home — and align the management with her values. I would not give a specific survival number without the oncology assessment, but I would be honest that the cancer is advanced and that the focus is increasingly on quality of life as well as length of life." [1]

DCE Short Case — Acute Pericarditis Discussion

Instruction

"This 32-year-old man has been admitted with chest pain. Examine his cardiovascular system and discuss your findings. You have 7 minutes for examination and 8 minutes for discussion." [1]

Key signs the patient demonstrates

• Sharp, pleuritic chest pain that the patient reports is worse on lying flat and breathing in, and better when sitting forward
• Pericardial friction rub — a scratching, leathery sound best heard at the left lower sternal border with the patient sitting forward in expiration. Three components may be audible
• Heart sounds otherwise normal; no murmurs
• No signs of heart failure — JVP normal, no oedema, lungs clear
• Mild low-grade fever [1]

Presentation template

"I examined this 32-year-old man's cardiovascular system. He is comfortable sitting forward at 45 degrees. The pulse is regular at 96 beats per minute, normal volume. Blood pressure is 118/76. The JVP is not elevated. [1]

The apex beat is normally situated in the 5th intercostal space, mid-clavicular line. On auscultation, with the patient sitting forward in expiration, there is a high-pitched scratching friction rub at the lower left sternal border, with two to three components. The heart sounds are otherwise normal with no murmurs. The lungs are clear. [1]

In summary, the pericardial friction rub in a young man with pleuritic positional chest pain is consistent with acute pericarditis." [1]

Discussion template

1. Summarise findings — "acute pericarditis confirmed by characteristic chest pain and a pericardial friction rub."
2. Request ECG — "I would request a 12-lead ECG, expecting diffuse concave ST elevation with PR depression and PR elevation in aVR."
3. Request echocardiogram — "to quantify any effusion and exclude tamponade."
4. Send bloods — "CRP and ESR for inflammatory markers, troponin to assess for myopericarditis, FBE, U&E, TFTs, ANA for underlying cause screening."
5. Management — "first-line treatment is an NSAID — ibuprofen 600 mg three times daily or aspirin 750 to 1000 mg three times daily — plus colchicine 0.5 mg twice daily for 3 months, supported by the ICAP trial. I would avoid corticosteroids first-line as they increase the risk of recurrence."
6. Activity restriction — "restrict strenuous activity and competitive sport until symptom-free with normalised CRP." [1]

Examiner: "Why does the pain improve on sitting forward?" [1]

"The pericardium shares its innervation with the parietal pleura and the chest wall via the phrenic nerve (C3 to C5). When the patient lies flat, the heart rests against the posterior pericardium, maximising contact between the inflamed visceral and parietal pericardial layers — this worsens the pain and the friction rub. When the patient sits up and leans forward, gravity lifts the heart away from the posterior pericardium, reducing the contact area between the inflamed surfaces and relieving the pain. This positional quality is one of the most discriminating bedside features of pericarditis, distinguishing it from the non-positional, pressure-like pain of cardiac ischaemia." [1]

Examiner: "What is the role of colchicine, and why not load it?" [1]

"Colchicine is an adjunct to the NSAID and its role is to reduce the risk of recurrence. The ICAP trial (PMID 23992557) showed that adding colchicine to conventional NSAID therapy for a first episode of acute pericarditis halved the recurrence rate at 18 months — from 37.5 percent with placebo to 16.7 percent with colchicine. The dose is weight-adjusted: 0.5 mg twice daily for patients over 70 kg and 0.5 mg daily for 70 kg or under, continued for 3 months. The older practice of giving a high-dose loading regimen (1 to 2 mg on day one) has been abandoned because it significantly increased gastrointestinal toxicity, particularly diarrhoea, without improving efficacy. The main side effect is diarrhoea — if it occurs, reduce to once-daily dosing. Colchicine works by inhibiting microtubule polymerisation and suppressing neutrophil function and interleukin-1 production, which is the inflammatory mediator now understood to drive recurrent pericarditis." [1]