Pericarditis
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More Specific Terms
Introduction
- Inflammation of the pericardium. Largely a clinical & to a lesser extent, electrocardiographic diagnosis.
Etiology
- idiopathic
- infection, especially viral
- 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
- 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
-
- generally presenting symptom
- may be intense, dull suggesting myocardial ischemia
- generally sharp, pleuritic, worsened with inspiration
- positional, relieved by sitting up, leaning forward
- 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 friction rub on chest auscultation
Laboratory
- complete blood count: Leukocytosis
- elevated erythrocyte sedimentation rate (ESR)
- markers of myocardial infarction may be slightly elevated with pericarditis alone [4]
- especially, troponin-I
Diagnostic-procedures
- 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)
- PR segment depression
- electrical alternans (alternating high & low voltage QRS complexes) with large pericardial effusions
- normalization of ST, PR & T wave changes occur late
- identifies pericardial effusion; absence of pericardial effusion does not rule out pericarditis [4]
- right atrial inversion suggests early cardiac tamponade
- 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
-
- increased size of heart if pericardial effusion > 250 mL
- 'water-bottle' configuration
Complications
- recurrent pericarditis (28%)
- pericardial tamponade
- chronic pericarditis
Differential-diagnosis
-
- post MI pericarditis mimics unstable angina
- sudden, severe onset of pain
- widening of mediastinum
- sharp chest pain with dyspnea
- ECG & CXR will distinguish
Management
- hospitalize
- rule out myocardial infarction
- emergent pericardiocentesis if evidence of pericardial tamponade
-
- severe pain refractory to NSAIDs or contraindications to NSAIDs
- 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 [4]
- recurrence & prevention of recurrence [6]
- duration of therapy 3-6 months
- may use in combination with NSAID for 3 months [4]
- codeine 15-30 mg PO every 4 hours
- non- acetylated salicylate for post- MI pericarditis
- anticoagulants are relatively contraindicated for risk of pericardial hemorrhage
- bedrest until resolution of pain
- patient education
- most cases self-limited resolving in 4-6 weeks
- follow-up:
- echocardiogram if clinical signs of constrictive pericarditis
More General Terms
Additional Terms
References
- Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 383-85
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 268-70
- Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 50-51
- Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
- Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1095
- Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91. PMID: [1]
