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Pericarditis

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Ovid: 5-Minute Sports Medicine Consult, The


Pericarditis
Kevin J. McAward
Basics
Description
  • Inflammation of the pericardial sac owing to multiple etiologies
  • Acute pericarditis:
    • Rapid in onset
    • Potentially complicated by effusion, which may lead to cardiac tamponade
  • Constrictive pericarditis: Results from chronic inflammation causing thickening and adherence of the pericardium to the heart
Epidemiology
Incidence and prevalence are essentially unknown owing to lack of epidemiologic studies.
Prevalence
Acute pericarditis is noted in 0.1% of hospitalized patients and 5% of ED-admitted patients with non-myocardial infarction (non-MI) chest pain.
Etiology
  • Idiopathic (most common)
  • Infectious: Viral most common:
    • Viral: Echovirus, coxsackievirus, adenovirus, varicella virus, Epstein-Barr virus, cytomegalovirus, hepatitis B virus, HIV
    • Bacterial: Staphylococcus, Streptococcus, Haemophilus, Salmonella, Legionella, tuberculosis
    • Fungal: Candida, Aspergillus, Histoplasma, Coccidomyces, Blastomyces, Nocardia
    • Parasitic: Amebiasis, Toxoplasmosis, Echinococcosis
    • Neoplastic: Lung cancer, breast cancer, lymphoma, leukemia, melanoma, primary neoplasm of peri/myocardium
  • Cardiac/aortic:
    • MI (Dressler syndrome)
    • Aortic dissection
  • Autoimmune diseases:
    • Connective tissue disease (systemic lupus erythematosus, rheumatoid arthritis, scleroderma)
    • Inflammatory bowel disease
  • Metabolic:
    • Uremia
    • Myxedema
  • Trauma:
    • Blunt
    • Penetrating
    • Iatrogenic
  • Drugs (rare):
    • Antiarrhythmics: Procainamide
    • Antibiotics: Isoniazid, penicillin
    • Antihypertensives: Hydralazine
    • Cromolyn sodium
    • Muscle relaxants: Dantrolene
    • Anticoagulants and thrombolytics
    • Chemotherapeutics: Doxorubicin
    • Anticonvulsants: Phenytoin
  • Amyloidosis
Diagnosis
2 of 4 major criteria should be present to make diagnosis:
  • Chest pain
  • Friction rub
  • ECG changes (described below)
  • Pericardial effusion
History
  • Chest pain: Classically described as worsened by lying flat and relieved by leaning forward
  • Typically sharp and constant pain located substernally
  • May radiate to bilateral trapezius owing to phrenic nerve innervation of the pericardium
  • May have pleuritic component
  • Fever and palpitations are described occasionally.
Physical Exam
  • Tachypnea
  • Tachycardia
  • Friction rub (noise of 2 inflamed layers of pericardium rubbing against each other):
    • Heard best at lower left sternal border with diaphragm of stethoscope
    • Intermittent and exacerbated by leaning forward
  • Muffled heart sounds
  • Signs of cardiac tamponade: Much less common in idiopathic cases:
    • Increased venous pressure (distended neck veins)
    • Pulsus paradoxus
    • Hypotension
Diagnostic Tests & Interpretation
  • Cardiac tests:
    • ECG:
      • Evolves over days/weeks
      • Initially, diffuse ST elevation with ST depression in aVR and V1, as well as depressed PR segments in most leads except aVR and V1
      • Later, ST segments normalize, and diffuse T-wave inversion is seen that may last indefinitely.
      • ECG changes eventually resolve over months.
      • Uremic patients may not have characteristic patterns.
    • Echocardiogram:
      • Recommended on every patient with pericarditis to check for effusion
      • Effusion not necessary for diagnosis
  • Imaging/special tests:
    • CXR:
      • Can be normal
      • May show enlargement of the cardiac silhouette
      • No change in heart size until >200 mL of fluid has accumulated in the pericardial sac
    • Chest CT scan: Useful for the detection of calcifications or thickening of the pericardium
    • Pericardiocentesis:
      • Only for severe cases with tamponade or unknown etiology
      • Used mainly for therapeutic treatment of tamponade and for diagnosis of suspected nonviral infectious pericarditis
Lab
  • Standard:
    • CBC
    • Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) may be elevated; helpful in following treatment.
    • Cardiac enzymes:
      • Helpful in distinguishing pericarditis from MI and myopericarditis
      • Reported elevated with the inflammation of pericarditis, typically to a lesser degree than infarction
  • Other considerations:
    • Viral serology including HIV
    • Blood cultures if high fever
    • Antinuclear antibodies (ANAs)
    • Metabolic profile
Diagnostic Procedures/Surgery
Tuberculin skin test may be done if tuberculosis is a diagnostic consideration.
Differential Diagnosis
  • Myopericarditis
  • Acute MI
  • Pulmonary embolism
  • Pneumothorax
  • Aortic dissection
  • Pneumonia
  • Empyema
  • Cholecystitis
  • Pancreatitis
  • Musculoskeletal chest wall pain

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Treatment
  • Idiopathic etiology (1,2):
    • Low risk:
      • NSAIDs or aspirin
      • Adding colchicine may be of benefit.
    • High risk: Admit for observation and treatment.
    • Recurrent:
      • Add colchicine to normal NSAID regimen
      • Prednisone for severely symptomatic recurrent disease
  • Tamponade: Pericardiocentesis for hemodynamic stabilization with testing of fluid for etiology
  • Underlying disease
  • Infectious: Antimicrobials if known organism
  • Neoplasm: Treat malignancy
ED Treatment
  • Treatment depends on the underlying etiology.
  • Idiopathic, viral, rheumatologic, and posttraumatic:
    • NSAID regimens effective
    • Corticosteroids reserved for refractory cases
  • Bacterial:
    • Aggressive treatment with IV antibiotics along with drainage of the pericardial space
    • Search for primary focus of infection
    • Therapy guided by determination of pathogen from pericardial fluid tests
  • Neoplastic: Treat underlying malignancy.
  • Uremia:
    • Intensive 2–6-wk course of dialysis
    • Caution should be used if using nonsteroidal medications.
  • Expected course/prognosis:
    • Majority of patients will respond to treatment within 2 wks.
    • Most have complete resolution of symptoms.
    • Small number progresses to recurrent bouts with eventual development of constrictive pericarditis or cardiac tamponade.
Medication
First Line
  • Ibuprofen 300–800 mg q6–8h until symptoms improve
  • Aspirin 800 mg q6–8h; preferred treatment in Dressler syndrome
  • May need to taper down over weeks to prevent recurrence (2)
Second Line
  • Colchicine 0.6 mg b.i.d.
  • Prednisone 1–1.5 mg/kg daily
Surgery/Other Procedures
Pericardiectomy for recurrent pericarditis has been found to be largely unsuccessful.
In-Patient Considerations
Admission Criteria
  • Fever >38°C
  • Subacute onset
  • Immunocompromised state
  • Anticoagulant use
  • Myopericarditis
  • Larger pericardial effusion
  • Tamponade
  • Trauma
Discharge Criteria
  • Most patients can be discharged quickly as long as they remain hemodynamically stable.
  • Close follow-up is recommended.
Ongoing Care
Return to play: Based on 36th Bethesda Conference guidelines (3):
  • No participation during acute phase regardless of etiology
  • Return is allowed when active disease has resolved.
    • Normalization of serum inflammatory markers (CRP, ESR)
    • No effusion per echocardiogram
  • If myocardial involvement, need to check eligibility requirements based on myocarditis
  • Residual constrictive pericarditis disqualifies an athlete from most sports.
Prognosis
  • Most patients do very well without any long-term sequelae.
  • 1% of acute idiopathic pericarditis patients go on to constrictive pericarditis; increased numbers if proven etiology.
  • 15–30% of acute idiopathic pericarditis patients go on to have recurrent disease.
  • NSAID treatment has no bearing on potential for complications.
References
1. Adler Y, Finkelstein Y, Guindo J, et al. Colchicine treatment for recurrent pericarditis: a decade of experience. Circulation. 1998;97:2183–2185.
2. Maisch B. Pericardial diseases, with a focus on etiology, pathogenesis, pathophysiology, new diagnostic imaging methods, and treatment. Curr Opin Cardiol. 1994;9:379–388.
3. 36th Bethesda Conference. J Am College Cardiol. 2005;45.
Additional Reading
Ariyarajah V, Spodick DH. Acute pericarditis: diagnostic cues and common electrocardiographic manifestations. Cardiol Rev. 2007;15:24–30.
Braunwald et al. Harrison's manual of medicine. 15th Edition. McGraw-Hill 2002
Imazio M. Evaluation and management of acute pericarditis. UpToDate. 2008
Lange RA, Hillis LD. Acute pericarditis. N Engl J Med. 2004;351:2195–2202.
Launbjerg J, Fruergaard P, Hesse B, et al. Long-term risk of death, cardiac events and recurrent chest pain in patients with acute chest pain of different origin. Cardiology. 1996;87:60–66.
Maisch B, Seferovi PM, Risti AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25:587–610.
Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart. 2004;90:252–254.
Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349:684–690.
Codes
ICD9
  • 074.21 Coxsackie pericarditis
  • 115.03 Histoplasma capsulatum pericarditis
  • 115.13 Histoplasma duboisii pericarditis
Clinical Pearls
  • Consider pericarditis as etiology of nonexertional chest pain.
  • Usually a benign course
  • Often complete resolution with course of oral NSAIDs
  • Important to rule out other causes of acute chest pain, eg, MI


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