Pericarditis

Aka: Pericarditis, Acute Pericarditis, Viral Pericarditis, Infectious Pericarditis

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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: Pericardial 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

  1. See Pericarditis Causes

V. Symptoms

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

VI. Symptoms: Chest Pain

  1. Pleuritic Chest Pain occurs in 95% of cases
  2. Timing: Abrupt onset over 5-10 minutes, lasting for hours to days
  3. Quality: Sharp Pleuritic Chest Pain
  4. Region: Substernal Chest Pain or left precordial Chest Pain
  5. Radiation
    1. Ridge of trapezius (inferior Scapular pole) due to left phrenic nerve irritation (Very specific for Pericarditis)
    2. Neck, Jaw or Shoulder (similar to Myocardial Infarction radiation)
  6. 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
  7. 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)
    1. Fever >101.3 F (38.5 C) may suggest more significant infection (e.g. Tuberculosis, Bacterial Infection)
  2. Sinus 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. High-pitched scratchy, squeeking or crunch sound of walking on snow
    3. Auscultate left sternal border or mid-clavicular line at second to fourth intercostal spaces
      1. 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
  6. Associated Myocarditis findings
    1. See Myocarditis
    2. Children may present with more subtle findings (e.g. Puffy Eyelids, Sinus Tachycardia)

VIII. Labs: Initial

  1. Serum Electrolytes
  2. Serum Troponin I (or other Cardiac Markers)
    1. Troponin I increased in 15-25% of cases (resolving after 7-14 days)
    2. Significant Troponin Increases are more suggestive of Myocarditis (or Acute Coronary Syndrome)
      1. Myocarditis is associated with increased risk of CHF or Arrhythmia
    3. Mild Troponin elevation may be seen with Pericarditis
      1. Mildly increased Troponin does not appear to confer overall 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

  1. Antinuclear Antibody
  2. Rheumatoid Factor
  3. Thyroid Stimulating Hormone (TSH)
  4. Quantiferon-TB (or Purified Protein Derivative, PPD)
  5. HIV Test

X. Diagnostics: Electrocardiogram (EKG)

  1. See EKG in Pericarditis
  2. Precaution
    1. Exclude Myocardial Infarction first
    2. Overdiagnosis and misdiagnosis of Pericarditis instead of true STEMI is most significant pitfall
  3. 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. May identify underlying cause (e.g. Tuberculosis, Lung Cancer)
    3. Rarely diagnostic for Pericarditis
    4. Pleural Effusion in 50% of cases
    5. Enlarged cardiac silhouette (water bottle heart)
      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 or evaluation for purulent Pericarditis (e.g. Staphylococcus aureus)

XII. Imaging: Echocardiogram

  1. Indications
    1. Recommended in all Pericarditis cases to evaluate for Pericardial Effusion and estimate ejection fraction
    2. Preferred Imaging technique indicated for signs of Cardiac Tamponade (Increased JVP or Pulsus Paradoxus)
    3. Identifies Pericardial Effusion and Cardiac Tamponade
  2. Findings
    1. Pericardial Effusions are present in 60% of Pericarditis cases (with most being small effusions, <1 cm wide)
    2. Echocardiogram is also used to evaluate ejection fraction
  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: 2-2.5 cm wide
    4. Very large Pericardial Effusion: >2.5 cm wide

XIII. Diagnosis: Requires 2 of the following 4 criteria

  1. Sharp Pleuritic Chest Pain
  2. Pericardial Friction Rub
  3. Typical changes associated with EKG in Pericarditis
  4. New or worsening Pericardial Effusion (more than trivial fluid)

XIV. Differential Diagnosis

  1. Acute Coronary Syndrome ( Myocardial Ischemia or Myocardial Infarction)
  2. Gastroesophageal Reflux, Gastritis or Peptic Ulcer Disease
  3. Pneumonia
  4. Myocarditis
  5. Pulmonary Embolism
  6. Cerebrovascular Accident
  7. Pneumothorax
  8. Hyperkalemia
  9. Pneumopericardium
  10. Sub-epicardial Hemorrhage
  11. Ventricular aneurysm
  12. Aortic Dissection
  13. Esophageal Rupture

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 (possible myopericarditis)

XVII. Management: Disposition

  1. Hospitalization Indications
    1. Anticoagulation therapy
    2. Fever >100.4 F
    3. Large Pleural Effusion by Echocardiogram (>2 cm wide)
    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

XVIII. Management: Medications

  1. Preacaution: Post-Myocardial Infarction Pericarditis
    1. Aspirin is first-line therapy for post-Myocardial Infarction Pericarditis (or Pericarditis and known Coronary Artery Disease)
      1. Aspirin 650-1000 mg every 6-8 hours 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. Consider concurrent GI prophylaxis with Proton Pump Inhibitor (e.g. Omeprazole)
    3. 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
    4. 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. Colchicine weaned after CRP drops to <3
        3. Weight > 70 kg (154 lb): 0.5 mg twice daily
        4. 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]
        2. Imazio (2013) N Engl J Med 369(16): 1522-8 [PubMed]
    5. 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. Uremic Pericarditis
        3. Refractory to NSAIDs and Colchicine
      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
    6. Antimicrobial agents (rarely indicated)
      1. Antibiotics for Bacterial Pericarditis
      2. Antifungals for fungal Pericarditis
      3. Lyme Disease
      4. Tuberculosis
      5. Trypansoma cruzi

XIX. Management: Infectious Pericarditis

  1. Uncommon (most cases are inflammatory - see above)
  2. Purulent Bacterial Pericarditis
    1. Typically empiric antibiotics, then guided by Pericardiocentesis fluid culture and sensitivity
    2. First-line antibiotics
      1. Vancomycin 15-20 mg/kg IV every 8-12 hours AND
      2. Ceftriaxone 2 g IV every 24 hours OR Cefepime 2 g IV every 12 hours
    3. Alternative regimen
      1. Vancomycin 15-20 mg/kg IV every 8-12 hours AND
      2. Ciprofloxacin 750 mg orally twice daily OR 400 mg IV twice daily
  3. Other infectious causes (consult infectious disease)
    1. Histoplasmosis (mild cases may be treated as inflammatory Pericarditis, WITHOUT Antifungals)
    2. Tuberculosis
  4. References
    1. (2016) Sanford Guide, accessed 4/8/2016

XX. Management: General

  1. General measures
    1. Head of bed elevated
    2. Humidified Supplemental Oxygen
    3. Cardiac monitor
    4. Pulse Oximetry
    5. Intravenous Access
  2. Emergent management for Unstable Patient
    1. Initial: Pericardiocentesis by experienced clinician
    2. Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
  3. Pericardiocentesis Indications
    1. Suspected Bacterial Pericarditis
    2. Cardiac Tamponade

XXI. Course

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

XXII. Follow-up

  1. Obtain formal Echocardiogram within a few days of initial diagnosis if not already done
  2. Clinic visit 1 week after onset of symptoms
  3. Repeat EKG at 4 weeks after onset of Pericarditis

XXIII. References

  1. Claudius in Herbert (2018) EM:Rap 18(8): 6
  2. Orman and Mattu in Herbert (2015) EM:Rap 15(7): 1-2
  3. Pacheco and Rawani-Patel (2019) Crit Dec Emerg Med 33(5): 3-11
  4. Swaminathan and Mattu in Herbert (2020) EM:Rap 20(9): 9-10
  5. Chiabrando (2020) J Am Coll Cardiol 75(1):76-92 [PubMed]
  6. Imazio (2007) Int J Cardiol 118(3): 286-94 [PubMed]
  7. Lange (2004) N Engl J Med 351:2195-202 [PubMed]
  8. LeWinter (2014) N Engl J Med 371(25): 2410-6 +PMID:25517707 [PubMed]
  9. Synder (2014) Am Fam Physician 89(7): 553-60 [PubMed]
  10. Tingle (2007) Am Fam Physician 76: 1509-14 [PubMed]
  11. Troughton (2004) Lancet 363: 717-27 [PubMed]

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