Pericardial Disease — Written Clinical Reasoning

SAQ 1 — Acute Pericarditis Risk Stratification and Management (20 marks, 30 minutes)

Prompt: Outline your integrated management plan for this patient, including risk stratification, investigation strategy, pharmacological management, and follow-up. Justify each decision with reference to evidence. [1]

Model Answer

Problem list (4 marks): [1]

1. Acute pericarditis, likely viral aetiology — confirmed by pleuritic positional chest pain, friction rub, and diffuse ST elevation with PR depression (two diagnostic criteria met; ESC/JACC require at least two of four)
2. Myopericarditis — mildly elevated troponin (0.12) with preserved biventricular function; no wall motion abnormalities. This does not indicate ischaemia
3. High-risk features present — fever over 38 degrees (38.6) AND oral anticoagulation (apixaban) are both ESC/JACC high-risk criteria mandating admission (ESC 2015, PMID 26320109; JACC 2020, PMID 31918837)
4. Paroxysmal atrial fibrillation on apixaban — a bleeding risk factor if pericardial inflammation progresses to a haemorrhagic effusion
5. Small pericardial effusion — currently not haemodynamically significant but requires monitoring [1]

Risk stratification — this patient MUST be admitted (3 marks): [1]

This patient has two independent high-risk features requiring hospital admission:

• Fever over 38 degrees — suggests possible non-viral or systemic cause; predicts a more complicated course and higher recurrence risk
• Oral anticoagulation (apixaban) — risk of haemopericardium if pericardial inflammation progresses; also a specific ESC/JACC high-risk criterion [1]

Other ESC/JACC high-risk features to screen for (absent here): large effusion over 2 cm, cardiac tamponade, immunosuppression, trauma, subacute onset, failure of initial outpatient NSAID therapy at one week. [1]

Investigation strategy (4 marks): [1]

Pharmacological management (6 marks): [1]

Activity restriction and follow-up (3 marks): [1]

• Restrict strenuous physical activity and competitive sport until symptom-free and CRP normalised — typically 3 months for competitive athletes (ESC 2015).
• Repeat echocardiogram at 1 week to ensure effusion is not expanding, and at completion of the aspirin course.
• Follow-up in physician or cardiology clinic at 1 week to review symptom response, CRP trend, and effusion size.
• Patient education — explain that pericarditis usually resolves fully but recurs in 15 to 30% of cases; advise that early return of symptoms should prompt urgent review.
• NSAID and colchicine weaning plan — taper aspirin over 2 to 4 weeks after CRP normalises; continue colchicine for the full 3 months regardless of symptom resolution. [1]

SAQ 2 — Investigation Interpretation: Constriction or Restriction? (15 marks, 20 minutes)

Prompt: A 60-year-old woman who had mediastinal radiotherapy for Hodgkin lymphoma 20 years ago presents with progressive dyspnoea, leg swelling, and abdominal distension over 6 months. JVP is elevated to 10 cm with a prominent Y descent that rises on inspiration. A high-pitched early diastolic sound is audible at the left lower sternal border. Echo shows EF 62%, thickened pericardium, septal bounce, medial e-prime 11 cm/s, and expiratory diastolic flow reversal in the hepatic veins. CT shows pericardial thickness 4 mm. Cardiac MRI shows pericardial late gadolinium enhancement but no myocardial LGE. BNP is 120 (normal under 100). [1]

Task: State the most likely diagnosis, explain how you differentiated it from the key alternative, and outline the management plan. [1]

Model Answer

Most likely diagnosis (3 marks): Constrictive pericarditis, radiation-induced, with possible transient (inflammatory) component given the pericardial late gadolinium enhancement on MRI. The presentation is right heart failure with a raised JVP showing prominent X and Y descent, Kussmaul sign (JVP rises on inspiration), and a pericardial knock — the classic bedside cluster. [1]

Differentiation from restrictive cardiomyopathy (6 marks): [1]

The key alternative is restrictive cardiomyopathy (which radiation can also cause — this is the trap). Five findings discriminate: [1]

The preserved e-prime is the single most reliable non-invasive discriminator: in constriction the myocardium is normal and the problem is the pericardium, so e-prime is preserved; in restriction the myocardium itself is stiff, so e-prime is reduced. [1]

Critical nuance (2 marks): The pericardial late gadolinium enhancement on MRI indicates active pericardial inflammation — this raises the possibility of transient (reversible) constriction, which can resolve with anti-inflammatory therapy rather than requiring immediate surgery. Up to 20% of constrictive presentations are transient. [1]

Management plan (4 marks): [1]

1. Trial of anti-inflammatory therapy for 2 to 3 months — given the pericardial LGE suggesting active inflammation, commence colchicine 0.5 mg BID with or without a low-dose NSAID (cautious given radiation-related kidney considerations), and reassess clinically and with echo at 3 months. If transient, the constrictive physiology may resolve.
2. Diurese cautiously — frusemide 20 to 40 mg daily for symptom control of congestion while awaiting reassessment. Avoid over-diuresis, which can precipitate hypotension (these patients are preload-dependent).
3. If constriction is fixed or progresses — refer for pericardiectomy at a specialist cardiothoracic centre. Perioperative mortality is higher in irradiated patients (up to 15 to 20%) because radiation damages the myocardium, coronaries, and valves, and the pericardium is densely fibrotic.
4. Assess for radiation-related comorbidities — coronary artery disease (radiation vasculopathy), valvular disease (aortic and mitral), and conduction disease — these coexist and may require separate management.
5. Acknowledge mixed physiology — radiation can cause BOTH constriction and restrictive cardiomyopathy. If the patient fails pericardiectomy or has clear myocardial LGE, the picture is mixed and management is primarily medical. [1]