pericarditis

Introduction

Inflammation of the pericardium.

Largely a clinical & to a lesser extent, electrocardiographic diagnosis.

Etiology

• idiopathic
• infection, especially viral
  • viral: coxsackie, varicella, influenza, HIV, hepatitis B, Epstein Barr virus
  • bacterial: Staphylococcus, Streptococcus, Mycobacterium, Neisseria gonorrhoeae, Treponema pallidum (syphilis)
  • fungal: Histoplasma, Candida, Blastomyces
  • parasitic: Echinococcus, Cysticercus, amoeba
• acute myocardial infarction
  • Dressler's syndrome onset 2-10 weeks post MI
• metastatic neoplasm
  • lung cancer
  • breast cancer
  • lymphoma & leukemia
• radiation therapy
  • 20% if entire pericardium is in field of radiation
  • shielding of heart reduces incidence to < 3%
  • may occur immediately or months later
    • up to 15-20 years later
    • pericarditis that occurs during radiation therapy generally does not preclude completion of therapy
• chronic renal failure (uremic pericarditis)
• connective tissue disease
  • lupus erythematosus
  • rheumatoid arthritis
  • rheumatic fever
  • polyarteritis nodosa
  • scleroderma
• pharmacologic agents
  • emetine
  • hydralazine
  • methysergide
  • procainamide
  • penicillins
  • warfarin
  • heparin
  • doxorubicin
• autoimmune reaction weeks to months post surgery or MI
• myxedema
• sarcoidosis
• amyloidosis
• associated with severe anemia
• associated with atrial septal defect
• aortic dissection with leakage into pericardial sac
• familial Mediterranean fever
• trauma, thoracic surgery

Epidemiology

• men affected more often than women
• adults affected more often than children

Clinical manifestations

• pleuritic chest pain
  • generally presenting symptom
  • generally sharp, pleuritic, worsened with inspiration
  • may be intense, dull suggesting myocardial ischemia
  • positional, relieved by sitting up, leaning forward
    • worsened by supine position
    • may be worsened by deep breaths or holding breath
  • the pericardium has few pain fibers
  • pain generally arises from inflammation of adjacent parietal pleura
  • persistent pain, hours or days in duration
• fever
• palpitations
• 2-3 component pericardial friction rub on chest auscultation
  • may be described as scratchy systolic & diastolic auscultatory sounds
  • may be best heard at left sternal border independent of respirations
  • described as vibratory systolic murmur
• may occur two days after myocardial infarction

Diagnostic criteria

• chest pain typical of pericarditis (see Clinical manifestations:)
• pericardial friction rub
• new ECG changes (see electrocardiogram)
• pericardial effusion (see echocardiogram)

* 2 of 4 criteria makes diagnosis of acute pericarditis

Laboratory

• complete blood count: Leukocytosis
• elevated erythrocyte sedimentation rate (ESR)
• markers of myocardial infarction may be slightly elevated with myopericarditis
  • especially, troponin-I
• leukocytes in pericardial fluid

Diagnostic procedures

• electrocardiogram
  • diffuse ST segment elevation
    • concave upward
    • generally present in all leads except aVR & V1
    • days later, ST segment returns to baseline
    • absence of reciprocal ST segment depression
  • T-wave inversion when ST segment returns to baseline
  • atrial premature contractions (APC)
  • atrial fibrillation
  • differentiate from early repolarization variant (ERV)
    • pericarditis: ST/T ratio > 0.25
    • ERV: ST/T ratio < 0.25
  • PR segment depression (except aVR)
  • electrical alternans (alternating high & low voltage QRS complexes) with large pericardial effusions
  • normalization of ST, PR & T wave changes occur late
  • no QT prolongation
  • anterior Q waves may be observed but no pathologic Q waves
  • no reciprocal ST segment or T-wave changes
• echocardiogram:
  • identifies pericardial effusion
    • initial testing
    • absence of pericardial effusion does not rule out pericarditis
  • right atrial inversion suggests early cardiac tamponade
• cardiac catheterization:
  • useful in differentiating cardiac tamponade, restrictive cardiomyopathy & constrictive pericarditis
• pericardiocentesis with pericardial biopsy
  • rarely indicated
  • diagnosis of suspected bacterial, tubercular or systemic inflammatory disease
  • pericardial effusion persisting > 3 months

Radiology

• Chest X-ray
  • increased size of heart if pericardial effusion > 250 mL
  • 'water-bottle' configuration

Complications

• recurrent pericarditis (28%)
  • lack to response to NSAIDs & treatment of initial episode with glucocorticoids increases risk of recurrence
• pericardial tamponade
• chronic pericarditis

Differential diagnosis

• unstable angina, myocardial ischemia
  • post MI pericarditis mimics unstable angina
• dissecting aneurysm
  • sudden, severe onset of pain
  • widening of mediastinum
• pneumothorax
  • sharp chest pain with dyspnea
  • ECG & CXR will distinguish
• pulmonary infarction
  • evidence of DVT
  • VQ scan, pulmonary angiogram to distinguish
• esophageal disorder
  • esophageal rupture
  • hiatal hernia
• constrictive pericarditis
• abdominal disorder presenting as chest pain
  • biliary colic due to cholecystitis or choledocholithiasis
• cardiac tamponade
  • hypotension, jugular venous distension
  • pulsus paradoxus (decrease in systolic blood pressure > 10 mm Hg during inspiration)
• Dressler's syndrome
  • onset of symptoms 2-10 weeks post myocardial infarction
  • pericarditis may be a manifestation of Dressler's syndrome
  • pleuritis, pleural effusion

Management

• hospitalize if high-risk features
  • rule out myocardial infarction
  • emergent pericardiocentesis if evidence of pericardial tamponade
  • patients without high-risk features (fever, leukocytosis, acute trauma, abnormal cardiac enzymes, immunosuppression, oral anticoagulant use, larger pericardial effusion, evidence of cardiac tamponade) may be managed as outpatients
• pharmacologic agents
  • NSAIDS
    • aspirin 650-975 mg PO QID
      • NSAID of choice when associated with MI
      • apparently full dose aspirin plus prasugrel Ok in elderly
    • indomethacin 50 mg PO TID
    • ibuprofen 400 mg PO QID
    • 3-4 weeks duration
  • colchicine
    • may combine with NSAID or alternative to NSAID if NSAID contraindicated
      • primary treatment (MKSAP,NEJM), recurrence & prevention of recurrence
      • most effective drug in preventing recurrence
      • addition of colchicine to NSAID improves rates of remission & recurrence
    • duration of therapy 3-6 months
    • may use in combination with NSAID or glucocorticoid for 3-6 months
  • hemodialysis for uremic pericarditis including stage G5 chronic kidney disease
  • prednisone or other glucocorticoid
    • severe pain refractory to NSAIDs & colchicine or contraindications to NSAIDs & colchicine
    • not advised for initial therapy of pericarditis
      • may increase risk of pericarditis recurrence
    • avoid post myocardial infarction as glucocorticoids inhibit myocardial healing
    • autoimmune-mediated pericarditis
    • uremic pericarditis not responsive to intensive hemodialysis
    • 40-60 mg PO QD until improved
    • taper by 5 mg every 3 days until 20 mg/day, then taper more slowly
    • steroid withdrawal results in recurrence of pain
    • months of therapy
    • no benefit for tuberculous pericarditis
  • codeine 15-30 mg PO every 4 hours
  • interleukin-1 trap rilonacept for resolution & prevention of recurrent pericarditis
  • non-acetylated salicylate for post-MI pericarditis
  • anticoagulants are relatively contraindicated for risk of pericardial hemorrhage
  • tuberculous pericarditis
    • four drug therapy for tuberculosis
    • prednisone
• bedrest until resolution of pain
• immunotherapy
  • no benefit for Myvobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis
• patient education
  • most cases self-limited resolving in 4-6 weeks
• follow-up:
  • echocardiogram if clinical signs of constrictive pericarditis

Notes

• case presentation

More general terms

• pericardial disease
• serositis

More specific terms

• constrictive pericarditis
• uremic pericarditis

Additional terms

• causes of pericarditis
• pericardial effusion