Pericarditis

Aka: Pericarditis, Acute Pericarditis, Viral Pericarditis, Infectious Pericarditis

1. See Also
   1. Pericardial Effusion
   2. Pericarditis Causes
   3. EKG in Pericarditis
2. Pathophysiology: Layers
   1. Parietal Pericardium
      1. Surrounds heart and limits end diastolic heart volume
      2. Closely adhered to the Great Vessels and has minimal elasticity
   2. Pericardial sac
      1. Between the two pericardial layers
      2. Typically contains less than 30 cc fluid
   3. Visceral Pericardium (epicardium)
      1. Delicate lining surrounding heart and Great Vessels
3. Etiology
   1. See Pericarditis Causes
4. Symptoms
   1. Exercise intolerance
   2. Fatigue
   3. Prodrome (if infectious)
      1. Fever
      2. Malaise
      3. Myalgias
5. Symptoms: Pleuritic Chest Pain
   1. Timing: Abrupt onset, lasting for hours to days
   2. Quality: Sharp Pleuritic Chest Pain
   3. Region: Substernal Chest Pain or left precordial Chest Pain
   4. Radiation
      1. Ridge of trapezius (Very specific for Pericarditis)
      2. Neck, Jaw or Shoulder
   5. Modifying Factors
      1. Provoked by swallowing or inspiration
      2. Positional
         1. Worse while lying down supine
         2. Better while sitting, leaning forward
6. Signs
   1. Fever (if infectious)
   2. Tachycardia
   3. Pericardial Friction Rub (pathognomonic for Pericarditis)
      1. Rarely heard in Pericarditis
      2. Crunch sound of walking on snow
   4. Distant heart sounds
   5. Tamponade signs
      1. Kussmaul's Sign
      2. Pulsus paradoxicus
      3. Jugular Venous Distention
7. Labs: Initial
   1. Complete Blood Count (CBC)
   2. Erythrocyte Sedimentation Rate (ESR)
   3. C-Reactive Protein
   4. Serum electrolytes
   5. Cardiac enzymes (Serum Troponin I) increased
8. Labs: Indicated for Cardiac Tamponade, unknown cause, and duration >7 days
   1. Antinuclear Antibody
   2. Rheumatoid Factor
   3. Purified Protein Derivative (PPD) and Sputum for Tuberculosis
9. Diagnosis
   1. See EKG in Pericarditis
   2. Chest XRay
      1. Useful in ruling out Pneumonia or Pneumothorax
      2. Rarely diagnostic for Pericarditis
      3. Pleural Effusion in 50% of cases
      4. Enlarged cardiac silhouette
         1. Difficult to identify (Compare with old films)
         2. Present only if Pericardial Effusion >250 ml
   3. Echocardiogram
      1. Preferred Imaging technique indicated for signs of Cardiac Tamponade (Increased JVP or Pulsus Paradoxus)
      2. Does not rule out Pericarditis if normal (May be normal in Pericarditis)
      3. Identifies Pericardial Effusion and Cardiac Tamponade
   4. MRI chest or CT chest
      1. Consider in inconclusive cases
   5. Pericardiocentesis Indications
      1. Suspected bacterial Pericarditis
      2. Cardiac Tamponade
10. Differential Diagnosis
    1. Myocardial Infarction
    2. Early Repolarization
    3. Myocarditis
    4. Pulmonary Embolus
    5. Cerebrovascular Accident
    6. Pneumothorax
    7. Hyperkalemia
    8. Pneumopericardium
    9. Sub-epicardial Hemorrhage
    10. Ventricular aneurysm
11. Complications
    1. Pericardial Effusion (40% of cases)
       1. Serous effusion: Viral Pericarditis
       2. Exudative effusion: Neoplastic, Tuberculosis and bacterial Pericarditis
    2. Cardiac Tamponade
       1. Uncommon in Viral Pericarditis (14%)
       2. Occurs in 60% of exudative cases listed above
    3. Constrictive Pericarditis
12. Management
    1. Hospitalization Indications
       1. Anticoagulation therapy
       2. Fever >100.4 F
       3. Large Pleural Effusion by Echocardiogram
       4. Cardiac Tamponade
       5. Immunocompromised Status
       6. Traumatic Pericarditis
       7. Myopericarditis
       8. Troponin I increased
    2. Indications for not admitting to hospital
       1. Age <40 years and
       2. Conditions on differential diagnosis unlikely and
       3. No signs of Cardiac Tamponade or large effusion and
       4. Cardiac enzymes normal and
       5. Adequate pain control and
       6. Outpatient monitoring available
    3. Medications
       1. Preacaution: Post-Myocardial Infarction Pericarditis
          1. Aspirin is first-line therapy for post-Myocardial Infarction Pericarditis
          2. NSAIDs and Corticosteroids are contraindicated in post-MI Pericarditis
             1. NSAIDs and Corticosteroids delay healing
       2. Non-Myocardial Infarction related Pericarditis
          1. First line: NSAIDs for 2 weeks
          2. Second line: Colchicine and Aspirin
             1. Aspirin 800 mg q6-8 hours for 7-10 days, then tapered over 3-4 weeks and
             2. Colchicine 1-2 mg on day 1 and then 0.5 to 1 mg/day for 3 months (divided dosing)
             3. Significantly reduces Pericarditis episode duration and recurrence rate
                1. Imazio (2005) Circulation 112: 2012-6
          3. Refractory cases: Prednisone 10 mg PO qd x1-2 weeks
             1. Avoid in most cases
             2. Increased risk of recurrence
             3. Taper to NSAIDs
          4. Antimicrobial agents (rarely indicated)
             1. Antibiotics for bacterial Pericarditis
             2. Antifungals for fungal Pericarditis
    4. Emergent management for unstable patient
       1. Initial: Pericardiocentesis by experienced clinician
       2. Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
    5. General measures
       1. Head of bed elevated
       2. Humidified Supplemental Oxygen
       3. Cardiac monitor
       4. Pulse oximetry
       5. Intravenous Access
13. Course
    1. Symptoms subside within 2 weeks
    2. Recurrence in 15% in a few months after initial episode
14. Follow-up
    1. Clinic visit 2 weeks after onset of symptoms
    2. Repeat EKG at 4 weeks after onset of Pericarditis
15. References
    1. Troughton (2004) Lancet 363: 717-27
    2. Lange (2004) N Engl J Med 351:2195-202
    3. Tingle (2007) Am Fam Physician 76: 1509-14