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Pericarditis
Aka: Pericarditis- See Also
- Etiology
- Symptoms: Prodrome
- Fever
- Malaise
- Myalgias
- Symptoms: Pleuritic Chest Pain
- Timing: Abrupt onset, lasting for hours to days
- Quality: Sharp Pleuritic Chest Pain
- Region: Substernal Chest Pain or left precordial Chest Pain
- Radiation
- Ridge of trapezius (Very specific for Pericarditis)
- Neck, Jaw or Shoulder
- Modifying Factors
- Provoked by swallowing or inspiration
- Positional
- Worse while lying down supine
- Better while sitting, leaning forward
- Signs
- Fever (if infectious)
- Tachycardia
- Pericardial Friction Rub (pathognomonic for Pericarditis)
- Tamponade signs
- Kussmaul's Sign
- Pulsus paradoxicus
- Labs: Initial
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate (ESR)
- C-Reactive Protein
- Serum electrolytes
- Cardiac enzymes (Serum Troponin I) increased
- Labs: Indicated for Cardiac Tamponade, unknown cause, and duration >7 days
- Diagnosis
- See EKG in Pericarditis
- Chest XRay
- Useful in ruling out Pneumonia or Pneumothorax
- Rarely diagnostic for Pericarditis
- Enlarged cardiac silhouette
- Difficult to identify (Compare with old films)
- Present only if Pericardial Effusion >250 ml
- Echocardiogram
- Preferred Imaging technique
- May be normal in Pericarditis
- Identifies Pericardial Effusion and Cardiac Tamponade
- MRI chest or CT chest
- Consider in inconclusive cases
- Pericardiocentesis Indications
- Suspected bacterial Pericarditis
- Cardiac Tamponade
- Differential Diagnosis
- Myocardial Infarction
- Early repolarization
- Myocarditis
- Pulmonary Embolus
- Cerebrovascular Accident
- Pneumothorax
- Hyperkalemia
- Pneumopericardium
- Sub-epicardial hemorrhage
- Ventricular aneurysm
- Complications
- Pericardial Effusion (40% of cases)
- Serous effusion: Viral Pericarditis
- Exudative effusion: Neoplastic, Tuberculosis and bacterial Pericarditis
- Cardiac Tamponade
- Uncommon in viral Pericarditis (14%)
- Occurs in 60% of exudative cases listed above
- Chronic Constrictive Pericarditis
- Pericardial Effusion (40% of cases)
- Management
- Hospitalization Indications
- Anticoagulation therapy
- Fever >100.4 F
- Large Pleural Effusion by echocardiogram
- Cardiac Tamponade
- Immunocompromised Status
- Traumatic Pericarditis
- Myopericarditis
- Troponin I increased
- Indications for not admitting to hospital
- Age <40 years and
- Conditions on differential diagnosis unlikely and
- No signs of Cardiac Tamponade or large effusion and
- Cardiac enzymes normal and
- Adequate pain control and
- Outpatient monitoring available
- Medications
- Preacaution: Post-Myocardial Infarction Pericarditis
- Aspirin is first-line therapy for post-Myocardial Infarction Pericarditis
- NSAIDs and Corticosteroids are contraindicated in post-MI Pericarditis
- NSAIDs and Corticosteroids delay healing
- Non-Myocardial Infarction related Pericarditis
- First line: NSAIDs for 2 weeks
- Second line: Colchicine and Aspirin
- Aspirin 800 mg q6-8 hours for 7-10 days, then tapered over 3-4 weeks and
- Colchicine 1-2 mg on day 1 and then 0.5 to 1 mg/day for 3 months (divided dosing)
- Significantly reduces Pericarditis episode duration and recurrence rate
- Refractory cases: Prednisone 10 mg PO qd x1-2 weeks
- Increased risk of recurrence
- Preacaution: Post-Myocardial Infarction Pericarditis
- Emergent management for unstable patient
- Initial: Pericardiocentesis by experienced clinician
- Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
- Hospitalization Indications
- Course
- Symptoms subside within 2 weeks
- Recurrence in 15% in a few months after initial episode
- Follow-up
- Clinic visit 2 weeks after onset of symptoms
- Repeat EKG at 4 weeks after onset of Pericarditis
- References