Acute Pericarditis

Definition
Inflammation of pericardium lasting < 6 weeks Characterized by triad of chest pain, pericardial friction rub, and serial electrocardiographic (ECG) changes

Epidemiology

Age
o

Occurs at all ages but is more frequent in young adults Incidence o 16% in postmortem studies o 0.1% of hospitalized patients o 5% of patients seen in emergency departments with chest pain but no myocardial infarction (MI)

Risk Factors
No identifiable risk factors exist for viral and idiopathic pericarditis, which are by far the most common causes. Risk is increased in patients with underlying conditions that can cause pericarditis.

Etiology
Infectious pericarditis o Viral (coxsackievirus A and B, echovirus, mumps, adenovirus, hepatitis, HIV) o Pyogenic (pneumococcus, streptococcus, staphylococcus, Neisseriaspecies, Legionella species) o Tuberculosis o Fungal (histoplasmosis, coccidioidomycosis, Candida species, blastomycosis) o Other infections (syphilitic, protozoal, parasitic) Noninfectious pericarditis o Acute idiopathic o Acute MI o Uremia o Neoplasia o Myxedema o Cholesterol o Chylopericardium o Trauma o Aortic dissection (with leakage into pericardial sac) o Irradiation therapy o Familial Mediterranean fever o Familial pericarditis o Whipples disease o Sarcoidosis

Pericarditis presumably related to hypersensitivity or autoimmunity o Rheumatic fever o Collagen vascular disease (systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, scleroderma, acute rheumatic fever, Wegeners granulomatosis) o Drug induced (e.g., procainamide, hydralazine, phenytoin, isoniazid, minoxidil, anticoagulants, methysergide) o Cardiac injury

Associated Conditions

Pericardial effusion Acute MI Pleuritis Pneumonitis

Symptoms & Signs

Chest pain o Important, but not an invariable symptom o Severe, retrosternal, and left precordial, referred to the back and the left trapezius ridge o Pleuritic o May be a steady, constricting pain that radiates into arms and resembles myocardial ischemia o Relieved by sitting up and leaning forward and intensified by lying supine o Usually present in the acute infectious types and in many of the forms presumed to be related to hypersensitivity or autoimmunity Pericardial friction rub o The most important physical sign o May have up to 3 components: presystolic, systolic, and diastolic The most frequent component is systolic. o High-pitched, scratching, grating sound o Sometimes only elicited when firm pressure with the diaphragm of the stethoscope is applied at the left lower sternal border o Heard most frequently during expiration with the patient in the sitting position o Rub is often inconstant; it may disappear and reappear the following day. ECG findings (see Figure 1)
o

Widespread elevation of ST segments Upward concavity is common.

Differential Diagnosis

2 or 3 standard limb leads and V2 to V6 usually involved Reciprocal ST segment depressions only in aVR and sometimes V1 Return to normal after several days, then T waves become inverted o Changes are secondary to acute subepicardial inflammation. o QRS complexes Usually no significant changes; no Q waves May see reduction in voltage with large pericardial effusions Pericardial effusion o Heart sounds may become faint o Friction rub may disappear o Apex impulse may vanish or move medial to the left border of cardiac dullness. o May lead to cardiac tamponade if effusion develops in a relatively short time In viral or idiopathic acute pericarditis o Antecedent infection of the respiratory tract is common. o Pleuritis and pneumonitis frequently accompany pericarditis. Fever may be present with viral or pyogenic pericarditis.

Diagnostic Approach

Acute MI o Elevations in serum biomarkers of myocardial damage in acute pericarditis are modest. o ECG changes can help differentiate. Pulmonary embolism Consider diagnosis in patients with: o Chest pain o Pericardial friction rub o Characteristic ECG changes Additional testing can confirm the diagnosis and possibly identify the underlying cause.

Laboratory Tests
Leukocyte count, erythrocyte sedimentation rate, and Creactive protein level are usually elevated, but these findings are nonspecific. Markedly elevated leukocyte count suggests purulent pericarditis. Plasma troponin concentrations are elevated in 3550 % of patients with acute pericarditis.

Serum MB creatine kinase level may also be elevated. Viral antibody titers and cultures are not useful clinically. Additional tests based on clinical presentation (e.g. HIV or antineutrophil antibodies)

Imaging
Echocardiography o Effectively identifies pericardial effusion (see Figure 2) Sensitive and specific Simple, noninvasive, and may be performed at the bedside Can identify accompanying cardiac tamponade o Allows localization and estimation of the quantity of pericardial fluid o Relatively echo-free space seen Between the posterior pericardium and left ventricular epicardium in small effusions Between the anterior right ventricle and the parietal pericardium just beneath the anterior chest wall in larger effusions CT or MRI o Can confirm pericardial fluid or thickening o May be superior to echocardiography in detecting loculated pericardial effusions and pericardial thickening Chest radiography o May demonstrate evidence of pericardial effusion "Water bottle" configuration of the cardiac silhouette (see Figure 3) Lucent pericardial fat lines may be seen deep within the cardiopericardial silhouette.

Diagnostic Procedures

Pericardiocentesis: removal of pericardial fluid o A needle attached to a properly grounded ECG lead is inserted into the pericardial space. Subxiphoid approach preferred Echocardiographic control used when possible o Indications for diagnostic pericardiocentesis Known or suspected purulent or neoplastic pericarditis o Fluid should be used for: Erythrocyte and leukocyte counts Cytologic examination Triglyceride measurement

Microscopic examination for organisms Culture o Pericardial effusion are nearly always an exudate. o Transudative pericardial effusions may occur in heart failure. o When diagnostic pericardiocentesis of a large effusion is done, as much fluid as possible should be removed. o Intrapericardial pressure should be measured before fluid is withdrawn. o Bloody fluid Commonly due to tuberculosis or neoplasm May also be found in rheumatic fever or uremic pericarditis, or after cardiac injury or MI

Treatment Approach
There is no specific treatment for most causes of pericarditis. Patients should be observed for development of pericardial effusion. Pericardiocentesis must be performed immediately for cardiac tamponade.

Specific Treatments
Medications Treat etiology: e.g. collagen vascular disease, remove offending drug therapy Anti-inflammatory agents

Aspirin, 650975 mg qid Indomethacin, 2575 mg qid Ibuprofen, 400800 mg qid o Prednisone, 4080 mg/d Colchicine, 0.6mg bid o Seems to be effective alone or in combination with ibuprofen but has not been tested in randomized trials o Preferred for patients who have recurrent pericarditis
o o o

Interventional procedures Pericardiocentesis to relieve pericardial pressure in manifestations of tamponade Pericardectomy for intractable prolonged pain or frequently recurrent episodes

Monitoring

Surgical drainage through limited thoracotomy may be required for: o Recurrent tamponade o Removal of loculated effusions o Obtaining of tissue for diagnosis

Complications

Patients should be observed frequently for development of pericardial effusion. If a large effusion is present, the patient should be hospitalized and watched closely for signs of tamponade. o Arterial and venous pressures and heart rate should be monitored. o Serial echocardiograms should be obtained. Cardiac tamponade o Results from accumulation of sufficient fluid in the pericardium to cause serious obstruction to the inflow of blood to the ventricles o May be fatal if not recognized and treated properly o Features Elevated intracardiac pressures Limited ventricular filling Reduced cardiac output o Signs and symptoms Paradoxical pulse: greater than normal (10 mmHg) inspiratory decrease in systolic arterial pressure Hypotension Elevation of jugular venous pressure May also develop slowly with clinical manifestations resembling those of heart failure, including dyspnea, orthopnea, hepatic engorgement, and jugular venous hypertension o Most common causes Neoplastic disease Idiopathic pericarditis Uremia May also result from bleeding into the pericardial space after cardiac operations and trauma or due to tuberculosis and hemopericardium Constrictive pericarditis

Prognosis

Course is brief and benign in most patients. o Symptoms typically last < 2 weeks. o Responds well to NSAIDs

Prevention ICD-9-CM

Small or mid-sized effusions usually resolve within weeks. Recurs in 25% of patients; recurrences are sometimes multiple and can lead to constrictive pericarditis. Indicators of a poor prognosis o Temperature > 38 C o Subacute onset o Immunosuppressed state o Pericarditis associated with trauma o Anticoagulant therapy o Myopericarditis o Large pericardial effusion o Cardiac tamponade
o

Colchicine may prevent recurrences.

420.9_ Other and unspecified acute pericarditis, (specific type of pericarditis specified by fifth digit)

See Also

Cardiac Tamponade Chest Pain Chronic Constrictive Pericarditis Management of Malignant Effusions Non-invasive Cardiac Imaging

Internet Sites
Professionals o Homepage American Heart Association o Pericarditis ClinicalTrials.gov Patients o Pericarditis MedlinePlus

General Bibliography
Hoit BD: Management of effusive and constrictive pericardial heart disease.Circulation 105:2939, 2002 [PMID:12081983] Lange RA, Hillis LD: Clinical practice. Acute pericarditis. N Engl J Med351:2195, 2004 [PMID:15548780] LeWinter M: Pericardial diseases, in Braunwalds Heart Disease, 7th ed, Zipes D et al (eds). Philadelphia, Saunders, 2005 This topic is based on Harrisons Principles of Internal Medicine, 16th edition, chapter 222, Pericardial Disease by E Braunwald.

PEARLS
In patients with acute chest pain, clinically differentiate from acute MI. o Younger age (< 40 years), absence of coronary risk factors, and presence of pericardial effusion support acute pericarditis. o Older age, presence of coronary risk factors, and absence of pericardial effusion support acute MI.