10. Acute Pericarditis

Definition

Acute inflammation of the pericardium (possibly with associated pericardial effusion).

Etiologies

  • Idiopathic (90%).
  • Post-MI (acute or delayed such as Dressler).
  • Infectious (TB, viral, fungal, bacterial).
  • Rheumatologic (RA and SLE most commonly).
  • Uremia.
  • Malignancy.
  • Aortic dissection.
  • Trauma (direct, post-operative, or radiation therapy).

Evaluation/Diagnosis

A clinical diagnosis (echo can show pericardial effusion or myocardial involvement), but should have at least 2/4 of criteria bolded below:

  • Symptoms: low grade fevers, malaise or myalgia with pleuritic substernal chest pain acutely.
  • Signs: tachycardia, pericardial rub (high-pitched, scratchy or grating sound best heard at left sternal border; often varies in intensity over time) and suggestive ECG changes (classically widespread ST-segment elevation, PR segment depression except in lead aVR – which can display PR elevation). Particular attention on exam to signs of tamponade (pulsus paradoxus, elevated JVP).
  • Laboratory results: leukocytosis, elevated ESR/CRP, troponin may be minimally elevated and a significant and/or prolonged elevation suggests myocardial involvement (myopericarditis). Consider ANA, TB testing, HIV, blood cultures, malignancy work-up depending on clinical context. Other viral testing is generally not clinically useful.
  • CXR may reveal enlarged cardiac silhouette with new or worsening pericardial effusion.
  • TTE recommended in patients with hemodynamic compromise. High risk features including significant effusion and cardiac tamponade.
  • Important differential diagnoses to consider including ACS and PE.

Management

Limited data to guide management. Treat underlying etiology.

  • Disease course is usually self-limited and most recover without any complications. Risk factors for worse outcome: immunocompromised, high fevers (>38˚C), large pericardial effusion, on oral anticoagulation, failure to respond to NSAIDs.
  • Patients without high risk features can be managed outpatient.
  • Medications for viral or idiopathic:
    • NSAIDs: aspirin in patients with recent MI (650mg PO Q6hrs x 4 weeks), ibuprofen 600mg PO TID (lower incidence of adverse effects), ketorolac, indomethacin should be avoided in CAD. Also provide gastric protection with PPI.
    • Colchicine 1g daily (after 2g loading) for 3 months to prevent recurrence after resolution of pain.
    • Steroids can be used if patient is unable to tolerate or do not respond to NSAIDs/colchicine.
  • Pericardiocentesis for concurrent pericardial effusions is indicated for purulent or neoplastic pericarditis or suspicion for tamponade (very large effusions). The diagnostic yield is low for small or midsize effusion of unknown etiology.

 

 

Little WC, Freeman GL.  Pericardial Disease. Circulation. 2006 113: 1622-1632.

Lange RA, Hillis LD. Clinical practice. Acute Pericarditis.N Engl J Med 2004;351:2195-2202.

Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun;85(6):572-93.