Classification and stages of development
According to the duration of the course, pericarditis is traditionally divided into three groups:
- Acute: lasts less than 6 weeks.
- Subacute: lasts from 6 weeks to 6 months.
- Chronic: persists for more than 6 months.
Morphologically, dry (fibrinous), effusion (exudative, including those with the development of cardiac tamponade), and constrictive (adhesive) pericarditis are distinguished. It is important to understand that these forms are often not isolated diseases, but represent the sequential dynamics of a single pathological process.
At the first stage, dry inflammation develops. If the process progresses, the second stage—exudation—begins, during which effusion accumulates in the pericardial cavity. The third stage is characterized by adhesive processes and the formation of constriction that compresses the heart.
Etiology and clinical significance
The etiological spectrum of pericardial inflammation is extremely broad. Very often, the exact cause cannot be found, in which case it is referred to as an idiopathic or non-specific process (as a rule, it proceeds acutely). Among infectious agents, viruses play a leading role, especially Coxsackie and ECHO viruses. The development of the disease is usually preceded by an acute inflammatory reaction with prodromal symptoms: low-grade fever, sore throat, and myalgia.
In clinical practice, pericarditis is extremely rarely an absolute isolated problem. It should be viewed from two perspectives:
- Sign of a known disease. The diagnosis is already confirmed (e.g., end-stage chronic kidney disease, systemic lupus erythematosus, or widespread infection).
- Onset of hidden pathology. Inflammation of the pericardium becomes the very first symptom of a formidable disease (e.g., tuberculosis, oncopathology, systemic vasculitis, or collagenoses).
Pathogenesis and clinical presentation of dry pericarditis
The essence of dry pericarditis lies in the formation of fibrin deposits on the visceral and parietal layers. This disrupts their normal gliding during heart contractions and creates prerequisites for adhesive processes.
The main symptom is pain syndrome, although it is not strictly mandatory. The pain is localized in the precordial region and often radiates to the trapezius muscles and arms. The intensity and duration of the pain can vary greatly. An increase in discomfort with coughing or changing body position is characteristic.
In addition to pain, patients may complain of shortness of breath and dysphagia (swallowing disorders). Quite often, inflammation of the adjacent pleura joins the process, causing additional pain associated with the act of breathing.
Physical examination
A pathognomonic (most specific) auscultatory symptom of dry pericarditis is the pericardial friction rub. This sound phenomenon is heard during both systole and diastole.
To reliably auscultate this rub, the correct technique must be followed:
- Topography: the optimal auscultation point is located at the left sternal border at the level of the III–IV intercostal spaces.
- Patient position: the rub is heard better when the patient is sitting or leaning forward.
- Respiration: auscultation is performed on deep expiration.
- Technique: the diaphragm of the stethoscope should be firmly pressed against the patient's chest.
Briefly: answers to topical questions
What ECG changes are characteristic of acute dry pericarditis?
Acute pericarditis on ECG is characterized by specific changes in the ST segment and PQ interval.
- ST segment changes are diffuse in nature (affecting most leads), concordant (unidirectional), and combined with a positive T wave.
- PQ (PR) interval changes — depression of the interval is noted.
The ST segment returns to the isoelectric line within several days.
What clinical signs are included in the classic Beck's triad in cardiac tamponade?
The classic Beck's triad in cardiac tamponade includes three main hemodynamic and auscultatory manifestations:
- Arterial hypotension
- Elevated jugular venous pressure (pulsation, jugular venous distension, jugular venous engorgement)
- Muffled heart sounds (or attenuation/damping of sounds)
For successful auscultation of the pericardial friction rub, remember the "4 P's": Position the patient, ask to take a deep expiration, Press the stethoscope, Listen at the left sternal border (III-IV intercostal space).
Class and exam questions
Is pericarditis always an independent disease?
No, it is rarely isolated. Most often, it is a symptom of an already known disease (CKD, SLE) or the first sign of a hidden pathology (oncology, tuberculosis).
How are the various morphological forms of pericarditis interrelated?
Dry, effusion, and constrictive pericarditis can act as stages of the same process: first, fibrin is deposited, then exudate appears, and finally adhesions form.
Where does pain most commonly radiate in pericardial inflammation?
Typical radiation of the pain syndrome is to the area of the trapezius muscles and into the arms. The pain also depends on body position and coughing.
What else to study on this topic
- Clinical presentation of effusion (exudative) pericarditis
- Cardiac tamponade as a complication
- Pathogenesis of constrictive (adhesive) pericarditis
- Specific pericarditis (uremic, tuberculous)
- Relationship of pericarditis with systemic vasculitides and collagenoses
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