15/06/2026
MasterThePACES
PACES Consultation Station: Pericarditis with Effusion
Key history points (bullet form)
· Pain character – sharp, pleuritic, worse on inspiration
· Positional relief – eases leaning forward, worse supine
· Timing – acute (days to weeks), recurrent (1–2 months), chronic (>3 months)
· Prodrome – recent viral illness (cough, sore throat, fatigue, low-grade fever)
· Red flags / associated symptoms – palpitations, SOB, dizziness, syncope, abdominal distension (effusion/tamponade)
· Causes to ask about – viral; HIV/TB, uraemia, cancer, autoimmune (RA, lupus); prior trauma/cardiac surgery/MI (post-cardiotomy or post-MI syndrome)
· Differential symptoms – cough/SOB (pneumonia), long-haul flight/swollen calf (PE), cardiac risk factors (MI)
Examination findings – must know
· Pericardial rub – squeaky, like walking on fresh snow (pathognomonic)
· Signs of tamponade (medical emergency)
· Beck’s triad: hypotension, raised JVP, muffled heart sounds
· Tachycardia (early compensatory sign)
· Pulsus paradoxus – systolic BP drop >10 mmHg on inspiration
· Kussmaul’s sign – JVP rises on inspiration
· Signs of underlying cause – e.g. rheumatoid hands, rash (SLE), uraemic frost
Differential diagnosis
· Pleurisy / pneumonia
· Acute pulmonary embolism
· Musculoskeletal chest pain
· Myocardial infarction (especially if troponin elevated – myopericarditis)
Investigations – key for PACES
· ECG – global saddle-shaped ST elevation, PR depression; low voltage (effusion); electrical alternans (large effusion, swinging heart)
· Bloods – troponin (may be raised in myopericarditis), U&E, CRP/ESR, autoantibodies
· CXR – globular enlarged cardiac silhouette; pleural effusion; exclude lung cancer
· Echocardiography – bright pericardium, effusion, RV diastolic / RA systolic collapse (tamponade), regional wall motion abnormality (myopericarditis)
· Cardiac MRI – meso-/epicardial late gadolinium enhancement (favours myopericarditis over MI)
· CT – thickened pericardium
· Diagnostic pericardiocentesis – if suspect malignant, bacterial, or bloody effusion
Treatment & complications (high yield)
· Acute pericarditis – usually self-limiting
· NSAIDs (ibuprofen) or aspirin; add colchicine (counsel on nausea, avoid liver/renal disease, check drug interactions)
· Recurrent cases – may need corticosteroids
· Tamponade – emergency
· Immediate: leg raise, IV fluid bolus
· Definitive: imaging-guided pericardiocentesis
· Pericardiocentesis complications – RV puncture, coronary/internal mammary injury, pneumothorax, liver laceration
· Chronic constrictive pericarditis – surgical pericardiectomy
