II. Epidemiology

  1. Accounts for 5% of Emergency Department Chest Pain cases
  2. Most typical patient is a male aged 20 to 50 years old
    1. However occurs in both genders and at all ages

III. Pathophysiology: Layers

  1. Parietal Pericardium
    1. Surrounds heart and limits end diastolic heart volume
    2. Closely adhered to the Great Vessels and has minimal elasticity
  2. Pericardial sac
    1. Between the two pericardial layers
    2. Typically contains less than 30 cc fluid (15-50 ml)
  3. Visceral Pericardium (epicardium)
    1. Delicate lining surrounding heart and Great Vessels

IV. Etiology

V. Symptoms

  1. Exercise intolerance
  2. Fatigue
  3. Prodrome (if infectious)
    1. Fever
    2. Malaise
    3. Myalgias

VI. Symptoms: Pleuritic Chest Pain (95% of cases)

  1. Timing: Abrupt onset, lasting for hours to days
  2. Quality: Sharp Pleuritic Chest Pain
  3. Region: Substernal Chest Pain or left precordial Chest Pain
  4. Radiation
    1. Ridge of trapezius (Very specific for Pericarditis)
    2. Neck, Jaw or Shoulder (similar to Myocardial Infarction radiation)
  5. Modifying Factors
    1. Not relieved with Nitroglycerin
    2. Pleuritic Chest Pain
      1. Provoked by swallowing, inspiration, cough
    3. Positional
      1. Worse while lying down supine
      2. Better while sitting, leaning forward
  6. Precaution
    1. Acute Myocardial Infarction may present with positional Pleuritic Chest Pain in 16% of cases
    2. Acute Myocardial Infarction may also present with Pericarditis

VII. Signs

  1. Fever (if infectious)
  2. Tachycardia
  3. Pericardial Friction Rub (pathognomonic for Pericarditis)
    1. Uncommonly heard in Pericarditis despite reported occurring in up to 85% of cases (typically transient)
    2. Scratchy, squeeking or crunch sound of walking on snow
    3. Auscultate with patient leaning forward and holding breath (distinguishes from pleural rub)
    4. Unlikely to be heard if Pericardial Effusion present
  4. Distant heart sounds
  5. Tamponade signs
    1. Kussmaul's Sign
    2. Pulsus paradoxicus
    3. Jugular Venous Distention

VIII. Labs: Initial

  1. Serum electrolytes
  2. Serum Troponin I (or other Cardiac Markers)
    1. Troponin I increased in 30-50% of cases (resolving after 7-14 days)
    2. Troponin Increase does not confer adverse outcome in Pericarditis
  3. Acute phase reactants increased
    1. Complete Blood Count (CBC)
    2. Erythrocyte Sedimentation Rate (ESR)
    3. C-Reactive Protein (CRP)
      1. Increased in 76% of Pericarditis cases
      2. Resolves within 85% of Pericarditis cases within 2 weeks of treatment onset

IX. Labs: Indicated for Cardiac Tamponade, unknown cause, and duration >7 days

X. Labs: Electrocardiogram (EKG)

  1. See EKG in Pericarditis
  2. Obtain serial EKGs
    1. EKG in Myocardial Infarction evolves over minutes to hours
    2. EKG in Pericarditis evolves over days

XI. Imaging

  1. Chest XRay
    1. Useful in ruling out Pneumonia or Pneumothorax
    2. Rarely diagnostic for Pericarditis
    3. Pleural Effusion in 50% of cases
    4. Enlarged cardiac silhouette
      1. Difficult to identify (Compare with old films)
      2. Present only if Pericardial Effusion >250 ml
  2. MRI chest or CT chest
    1. Consider in inconclusive cases

XII. Imaging: Echocardiogram

  1. Indications
    1. Preferred Imaging technique indicated for signs of Cardiac Tamponade (Increased JVP or Pulsus Paradoxus)
    2. Identifies Pericardial Effusion and Cardiac Tamponade
  2. Efficacy
    1. Pericardial Effusions are present in 60% of Pericarditis cases (with most being small effusions, <1 cm wide)
  3. Precautions
    1. Does not rule out Pericarditis if normal (May be normal in Pericarditis)
  4. Effusion grading
    1. Mild effusion: <1 cm wide
    2. Moderate effusion: 1-2 cm wide
    3. Large Pericardial Effusion: 2 cm wide

XIII. Diagnosis: Requires 2 of the following

XV. Complications

  1. Pericardial Effusion (60% of cases)
    1. See Echocardiogram above
    2. Serous effusion: Viral Pericarditis
    3. Exudative effusion: Neoplastic, Tuberculosis and bacterial Pericarditis
  2. Cardiac Tamponade
    1. Uncommon in Viral Pericarditis or idiopathic Pericarditis (5-15%)
    2. Occurs in 60% of exudative cases listed above
  3. Constrictive Pericarditis

XVI. Evaluation: Severe Pericarditis predictive factors

  1. Major criteria
    1. Fever >100.4 F (38 C)
    2. Subacute onset
    3. Cardiac Tamponade findings
    4. Large Pericardial Effusion (>2 cm wide)
    5. Failed NSAIDs for 7 days
  2. Minor criteria
    1. Immunocompromised
    2. Oral Anticoagulants
    3. Pericarditis due to acute trauma
    4. Troponin Increased (myopericarditis)

XVII. Management

  1. Hospitalization Indications
    1. Anticoagulation therapy
    2. Fever >100.4 F
    3. Large Pleural Effusion by Echocardiogram
    4. Cardiac Tamponade
    5. Immunocompromised Status
    6. Traumatic Pericarditis
    7. Myopericarditis
    8. Troponin I increased
  2. Indications for not admitting to hospital
    1. Age <40 years and
    2. Conditions on differential diagnosis unlikely and
    3. No signs of Cardiac Tamponade or large effusion and
    4. Cardiac enzymes normal and
    5. Adequate pain control and
    6. Outpatient monitoring available
  3. Medications
    1. Preacaution: Post-Myocardial Infarction Pericarditis
      1. Aspirin is first-line therapy for post-Myocardial Infarction Pericarditis
        1. Aspirin 650-1000 mg four times daily for 7-10 days and then tapered over 4 weeks
      2. NSAIDs and Corticosteroids are contraindicated in post-MI Pericarditis
        1. NSAIDs and Corticosteroids delay healing
    2. Non-Myocardial Infarction related Pericarditis
      1. Consider adjusting medication protocol and dosing based on acute phase reactant levels
      2. First line: NSAIDs for 2-4 weeks
        1. Ibuprofen 600 to 800 mg every 6-8 hours tapered over 4 weeks
        2. Indomethacin 25-50 mg three times daily tapered over 4 weeks
      3. Second line: Colchicine and Aspirin
        1. Aspirin 800 mg q6-8 hours for 7-10 days, then tapered over 3-4 weeks and
        2. Colchicine 1-2 mg on day 1 and then 0.5 to 1 mg/day for 3 months (divided dosing)
          1. See Colchicine for adverse effects and lab monitoring
          2. Weight > 70 kg (154 lb): 0.5 mg twice daily
          3. Weight <70 kg (154 lb): 0.5 mg once daily
        3. Significantly reduces Pericarditis episode duration and recurrence rate
          1. Imazio (2005) Circulation 112: 2012-6 [PubMed] (or open in [QxMD Read])
          2. Imazio (2013) N Engl J Med 369(16): 1522-8 [PubMed] (or open in [QxMD Read])
      4. Refractory cases: Prednisone 10 mg PO qd x1-2 weeks
        1. Avoid in most cases
          1. Increased risk of recurrence, especially in Viral Pericarditis (Odds Ratio >4)
        2. Indications
          1. Connective tissue disease or autoimmune condition
          2. Uremia
        3. Protocol
          1. Prednisone 1 mg/kg/day tapering to 0.25 mg/kg/day and then to NSAIDs over 6-8 weeks
          2. Taper to NSAIDs and/or Colchicine
      5. Antimicrobial agents (rarely indicated)
        1. Antibiotics for bacterial Pericarditis
        2. Antifungals for fungal Pericarditis
  4. Emergent management for unstable patient
    1. Initial: Pericardiocentesis by experienced clinician
    2. Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
  5. Pericardiocentesis Indications
    1. Suspected bacterial Pericarditis
    2. Cardiac Tamponade
  6. General measures
    1. Head of bed elevated
    2. Humidified Supplemental Oxygen
    3. Cardiac monitor
    4. Pulse Oximetry
    5. Intravenous Access

XVIII. Course

  1. Symptoms typically subsides within 2 weeks
  2. Recurrence in 15% in a few months after initial episode

XIX. Follow-up

  1. Clinic visit 2 weeks after onset of symptoms
  2. Repeat EKG at 4 weeks after onset of Pericarditis

Images: Related links to external sites (from Google)

Ontology: Pericarditis (C0031046)

Definition (NCI) An inflammatory process affecting the pericardium.
Definition (NCI) A disorder characterized by irritation to the layers of the pericardium (the protective sac around the heart).
Definition (MSH) Inflammation of the PERICARDIUM from various origins, such as infection, neoplasm, autoimmune process, injuries, or drug-induced. Pericarditis usually leads to PERICARDIAL EFFUSION, or CONSTRICTIVE PERICARDITIS.
Concepts Disease or Syndrome (T047)
MSH D010493
SnomedCT 3238004
French PERICARDITE, Péricardite SAI, Péricardite
English PERICARDITIS, Pericarditis, NOS, Pericarditis, pericarditis (diagnosis), pericarditis, Pericarditis NOS, Pericarditis [Disease/Finding], an inflammation of the membrane surrounding the heart, Pericarditis (disorder), inflammation; pericardium, pericardium; inflammation
Portuguese PERICARDITE, Pericardite NE, Pericardite
Spanish PERICARDITIS, Pericarditis NEOM, pericarditis (trastorno), pericarditis, Pericarditis
German PERIKARDITIS, Perikarditis NNB, Perikarditis, Herzbeutelentzündung
Dutch pericarditis NAO, ontsteking; pericard, pericard; ontsteking, pericarditis, Pericarditis
Italian Pericardite NAS, Pericardite
Japanese 心膜炎, 心膜炎NOS, シンマクエン, シンマクエンNOS
Swedish Hjärtsäcksinflammation
Czech perikarditida, Perikarditida NOS, Perikarditida
Finnish Sydänpussitulehdus
Russian PERIKARDIT, ПЕРИКАРДИТ
Polish Zapalenie osierdzia
Hungarian Pericarditis, Pericarditis k.m.n.

Ontology: Acute pericarditis (C0155679)

Concepts Disease or Syndrome (T047)
ICD9 420.90, 420
ICD10 I30 , I30.9
SnomedCT 155333007, 194914005, 194920006, 15555002, 194902002
English PERICARDITIS, ACUTE, Acute pericarditis, NOS, Acute pericarditis - unspecified, Acute pericarditis NOS, Acute pericarditis, unspecified, Acute pericarditis-unspecified, acute pericarditis (diagnosis), acute pericarditis, PERICARDITIS ACUTE, Acute pericarditis - unspecified (disorder), Acute pericarditis NOS (disorder), Pericarditis;acute, pericarditis acute, Acute pericarditis, Acute pericarditis (disorder), acute; pericarditis, pericarditis; acute
Dutch acute pericarditis, acute pericarditis, niet-gespecificeerd, acuut; pericarditis, pericarditis; acuut, Acute pericarditis, niet gespecificeerd, Acute pericarditis
French Péricardite aiguë, Péricardite aiguë non précisée
German akute Perikarditis, akute Perikarditis, unspezifisch, Akute Perikarditis, nicht naeher bezeichnet, Akute Perikarditis
Italian Pericardite acuta non specificata, Pericardite acuta
Portuguese Pericardite aguda, Pericardite aguda NE
Spanish Pericarditis aguda, Pericarditis aguda no especificada, Acute pericarditis, pericarditis aguda (trastorno), pericarditis aguda no especificada (trastorno), pericarditis aguda no especificada, pericarditis aguda, SAI (trastorno), pericarditis aguda, SAI, pericarditis aguda
Japanese 急性心膜炎, 急性心膜炎、詳細不明, キュウセイシンマクエンショウサイフメイ, キュウセイシンマクエン
Czech Akutní perikarditida, Akutní perikarditida, blíže neurčená
Korean 상세불명의 급성 심장막염, 급성 심장막염
Hungarian Heveny szívburokgyulladás, k.m.n., Acut pericarditis

Ontology: Infectious pericarditis (C0265147)

Concepts Disease or Syndrome (T047)
ICD10 I30.1
SnomedCT 41739008
English INFECTIOUS PERICARDITIDES, Infectious pericarditis, NOS, 3-92 INFECTIOUS PERICARDITIDES, Pericarditis infective, Infective pericarditis, Infectious pericarditis, Infectious pericarditis (disorder), infective; pericarditis, pericarditis; infective, Pericarditis, infective NOS
Italian Infezione del pericardio, Pericardite infettiva
Japanese 感染性心膜炎, カンセンセイシンマクエン
Czech Perikarditida infekční, Infekční perikarditida
Korean 감염성 심장막염
Hungarian Fertőzéses pericarditis, infectiv pericarditis
Dutch infectieus; pericarditis, pericarditis; infectieus, Infectieuze pericarditis, pericarditis infectieus
Spanish pericarditis infecciosa (trastorno), pericarditis infecciosa, Pericarditis infecciosa, Pericarditis infecciosas
Portuguese Pericardirte infecciosa, Pericardite infecciosa
French Pericardite infectieuse, Péricardites infectieuses
German Infektioese Perikarditis, Perikarditis infektioes

Ontology: Viral pericarditis (C0276139)

Concepts Disease or Syndrome (T047)
ICD10 I30.1 , B33.23
SnomedCT 233882005, 70189005, 194915006
English VIRAL PERICARDITIS, Viral pericarditis, NOS, Viral pericarditis NOS, Pericarditis viral NOS, PERICARDITIS VIRAL, viral pericarditis (diagnosis), viral pericarditis, Viral pericarditis NOS (disorder), pericarditis viral, Viral pericarditis, Viral pericarditis (disorder), pericarditis; viral, pericarditis; virus, viral; pericarditis, virus; pericarditis
Italian Pericardite virale, Pericardite virale NAS
Dutch pericarditis viraal NAO, pericarditis; viraal, pericarditis; virus, viraal; pericarditis, virus; pericarditis, virale pericarditis
French Péricardite virale SAI, Péricardite virale
German Perikarditis viral NNB, virale Perikarditis
Portuguese Pericardite viral NE, Pericardite viral
Spanish Pericarditis vírica NEOM, Viral pericarditis NOS, pericarditis viral (trastorno), pericarditis viral, SAI (trastorno), pericarditis viral, SAI, pericarditis viral, pericarditis virósica, Pericarditis vírica
Japanese ウイルス性心膜炎, ウイルス性心膜炎NOS, ウイルスセイシンマクエンNOS, ウイルスセイシンマクエン
Czech Virová perikarditida NOS, Virová perikarditida
Hungarian vírusos pericarditis, Viralis pericarditis k.m.n.