Pericarditis

See Also

Epidemiology

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

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. Fluid reduces friction between the two layers
3. Visceral Pericardium (epicardium)
  1. Delicate lining surrounding heart and Great Vessels
Innervation
1. Afferent signals (sensory) from phrenic nerve
2. Efferent signals (motor) via Vagus Nerve and sympathetic trunk

Causes

See Pericarditis Causes

Symptoms
General

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

Symptoms
Chest Pain

Pleuritic Chest Pain occurs in 90 to 95% of cases
Timing: Abrupt onset over 5-10 minutes, lasting for hours to days
Quality: Sharp Pleuritic Chest Pain
Region: Substernal Chest Pain or left precordial Chest Pain
Radiation
1. Neck, Jaw or Shoulder (similar to Myocardial Infarction radiation)
2. Ridge of trapezius (Very specific for Pericarditis)
  1. Superior aspect of trapezius Running between Shoulder and cervical neck
  2. Pain is via left phrenic nerve irritation
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
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

Signs

Fever (if infectious cause)
1. Fever >101.3 F (38.5 C) may suggest more significant infection (e.g. Tuberculosis, Bacterial Infection)
Sinus Tachycardia
Pericardial Friction Rub
1. Pathognomonic for Pericarditis (Test Specificity approaches 100%)
2. Uncommonly heard in Pericarditis despite reported occurring in up to 30 to 85% of cases (typically transient)
  1. Unlikely to be heard if Pericardial Effusion present
3. High-pitched, triphasic, scratchy, squeeking or crunch sound of walking on snow
4. 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)
Distant heart sounds
Tamponade signs
1. Kussmaul's Sign
2. Pulsus paradoxicus
3. Jugular Venous Distention
Associated Myocarditis findings
1. See Myocarditis
2. Children may present with more subtle findings (e.g. Puffy Eyelids, Sinus Tachycardia)

Labs
Initial

Complete Blood Count (CBC)
Serum Electrolytes
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. Exclude Myocardial Infarction (including STEMI)!
  2. 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
Acute phase reactants increased
1. Erythrocyte Sedimentation Rate (ESR)
2. C-Reactive Protein (CRP)
  1. Increased in 76% of Pericarditis cases
  2. Resolves within 85% of Pericarditis cases within 2 weeks of treatment onset

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

Antinuclear Antibody
Rheumatoid Factor
Thyroid Stimulating Hormone (TSH)
Quantiferon-TB (or Purified Protein Derivative, PPD)
HIV Test

Diagnostics
Electrocardiogram (EKG)

See EKG in Pericarditis
Precaution
1. Exclude Myocardial Infarction first
2. Overdiagnosis and misdiagnosis of Pericarditis instead of true STEMI is the most significant pitfall
3. However, in true Pericarditis (when MI is excluded), EKG changes alone are NOT associated with a worse prognosis
Obtain serial EKGs
1. EKG in Myocardial Infarction evolves over minutes to hours
2. EKG in Pericarditis evolves over days

Imaging
General

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
CT Chest with IV Contrast (and EKG synchronization)
1. Contrast enhancement and pericardial thickening >2 mm at the right ventricular wall
2. Degree of attentuation may identify Purulent Pericarditis
MRI chest with gadolinium contrast
1. Consider in inconclusive cases
2. Defines cardiac morphology and function, pericardial mobility and inflammation
3. May identify Purulent Pericarditis (e.g. Staphylococcus Aureus)
4. May identify constrictive Pericarditis
  1. Pericardial thickening
  2. Ventricular chamber flattening and septal flattening
  3. Increased early ventricular filling and decreased late ventricular filling

Imaging
Echocardiogram

Precautions
1. Does not rule out Pericarditis if normal (May be normal in Pericarditis)
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
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
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
Less common findings
1. Constrictive Pericarditis
  1. Septal wall motion variation correlating with respiration
  2. Further assessed by flow velocities at mitral valve, tricuspid valve and hepatic vein

Diagnosis
Requires 2 of the Following 4 Criteria (ESC 2004/2015 guidelines)

Characteristic sharp Pleuritic Chest Pain
Pericardial Friction Rub
Typical changes associated with EKG in Pericarditis
New or worsening Pericardial Effusion (more than trivial fluid)

Differential Diagnosis

Acute Coronary Syndrome ( Myocardial Ischemia or Myocardial Infarction)
Gastroesophageal Reflux, Gastritis or Peptic Ulcer Disease
Pneumonia
Myocarditis
Pulmonary Embolism
Cerebrovascular Accident
Pneumothorax
Hyperkalemia
Pneumopericardium
Sub-epicardial Hemorrhage
Ventricular aneurysm
Aortic Dissection
Esophageal Rupture

Evaluation
Severe Pericarditis Predictive Factors (1 or more major or minor criteria)

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
Minor criteria
1. Immunocompromised
2. Oral Anticoagulants
3. Pericarditis due to acute Trauma
4. Troponin Increased (possible myopericarditis)

Management
General

General measures
1. Head of bed elevated
2. Humidified Supplemental Oxygen (as needed for Hypoxia)
3. Cardiac monitor
4. Pulse Oximetry
5. Intravenous Access
Pericardiocentesis Indications
1. Suspected Bacterial Pericarditis
2. Cardiac Tamponade
Emergent management for Unstable Patient
1. Initial: Pericardiocentesis by experienced clinician (typically performed in catheterization lab in U.S.)
2. Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
Athletes
1. Acute Pericarditis
  1. No competitive sports for 3 months
2. Acute myopericarditis
  1. No competitive sports for 3 to 6 months
3. May return to play earlier if negative markers
  1. Normal Serum biomarkers (e.g. Troponin, C-Reactive Protein)
  2. Normal Left Ventricular Function
  3. Nomal Electrocardiogram

Management
Disposition

Hospitalization Indications
1. Anticoagulation therapy
2. Fever >100.4 F
3. Leukocytosis
4. Large Pleural Effusion by Echocardiogram (>2 cm wide)
5. Cardiac Tamponade
6. Immunocompromised Status
7. Traumatic Pericarditis
8. Myocarditis or myopericarditis
9. Troponin Increased
10. Subacute onset
Indications for not admitting to hospital (all criteria met)
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

Management
Medications

Preacaution: Post-Myocardial Infarction Pericarditis
1. See Post-MI Pericarditis
2. 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
3. NSAIDs and Corticosteroids are contraindicated in Post-MI Pericarditis
  1. NSAIDs and Corticosteroids delay healing
Non-Myocardial Infarction related Pericarditis
1. Consider adjusting medication protocol and dosing based on symptoms and acute phase reactant levels
2. Consider concurrent GI prophylaxis with Proton Pump Inhibitor (e.g. Omeprazole)
3. First line: NSAIDs for 2 to 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. Combine with Proton Pump Inhibitor for Gastrointestinal Prophylaxis
4. Second line: Colchicine (added to NSAIDs or Corticosteroids)
  1. Colchicine
    1. Dose 1-2 mg on day 1 and then 0.5 to 1 mg/day for 3 months (divided dosing)
    2. See Colchicine for adverse effects and lab monitoring
    3. Colchicine weaned after CRP drops to <3
    4. Weight > 70 kg (154 lb): 0.5 mg twice daily
    5. Weight <70 kg (154 lb): 0.5 mg once daily
  2. 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. Third-Line: Corticosteroids for Refractory cases or NSAIDs Contraindicated
  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
    4. NSAIDs contraindicated
      1. Gastrointestinal Bleeding such as Peptic Ulcer Disease
      2. Anticoagulation
  3. Protocol
    1. Prednisone
      1. Typical Dose: 1 mg/kg/day tapering to 0.25 mg/kg/day
      2. Alternative short course, lower dose: 10 mg orally daily for 1-2 weeks
    2. Taper to NSAIDs and/or Colchicine over 6-8 weeks
6. Fourth Line: Refractory Cases
  1. Azathioprine
  2. Intravenous Immunoglobulin
7. Antimicrobial Agents (indicated only in suppurative cases)
  1. Antibiotics for Bacterial Pericarditis
  2. Antifungals for Fungal Pericarditis
  3. Lyme Disease
  4. Tuberculous Pericarditis
  5. Trypansoma cruzi

Management
Infectious Causes

Viral Pericarditis
1. See Pericarditis Causes for a full list of viral causes
2. Viruses (esp. Coxsackievirus) are the most common causes of Pericarditis (represent 80 to 90% of cases)
3. Management as above (e.g. NSAIDs, Colchicine) and specific viral cause is typically not identified
Tuberculous Pericarditis
1. See Tuberculous Pericarditis
2. Most common cause of Pericarditis in developing world (esp. with HIV Infection)
3. See Tuberculous Pericarditis
4. See Active Tuberculosis Treatment
Non-Tuberculous Bacterial Pericarditis
1. See Bacterial Pericarditis (Purulent Pericarditis)
2. Represent <1% of Pericarditis cases in Western Europe and U.S.
3. Non-Tuberculous Bacterial Causes are Uncommon
  1. Most cases are instead viral induced and inflammatory (see Pericarditis Causes)
4. Associated with ill or septic appearing, febrile patients with worse prognosis
Fungal Pericarditis
1. See Fungal Pericarditis (Mycotic Pericarditis)
2. Fungal Pericarditis is rare
3. Consult infectious disease
4. More common in Immunocompromised and malnourished patients
Parasitic Pericarditis
1. Parasitic Pericarditis is rare
2. Consult infectious disease
3. Causes include Echinococcosis, Toxoplasma, Trypanosoma cruzi and Entamoeba histolytica (Amebiasis)
4. Treat the specific Parasite infection

Course

Symptoms typically subsides within 2 weeks
Recurrence in 15% (up to one third of patients) in a few months after initial episode

Complications

Recurrent or Persistent Pericarditis
1. Relapsing Pericarditis (Recurrent Pericarditis)
  1. Recurrence after 4 to 6 weeks of symptom free period (occurs in up to one third oif patients)
2. Incessant Pericarditis
  1. Pericarditis persisting <3 months
3. Chronic Pericarditis
  1. Pericarditis persisting >3 months
Pericardial Effusion (60% of cases)
1. See Echocardiogram above
2. Serous effusion: Viral Pericarditis
3. Exudative effusion: Neoplastic, Tuberculosis and Bacterial Pericarditis
Cardiac Tamponade
1. Uncommon in Viral Pericarditis or idiopathic Pericarditis (5-15%)
2. May occur with even small Pericardial Effusions that accumulate rapidly
3. Occurs in 60% of exudative cases listed above (esp. Bacterial or Uremic Pericarditis)
Constrictive Pericarditis
1. Longterm complication secondary to pericardial scarring and decreased pericardial elasticity
2. Systolic function preserved, but diastolic filling is decreased
Myocarditis
1. Occurs in up to one third of Pericarditis cases
Other associated complications
1. Left Ventricular Dysfunction
2. Arrhythmias

Follow-up

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

References

Claudius in Herbert (2018) EM:Rap 18(8): 6
Klasek and Alblaihed (2023) Crit Dec Emerg Med 37(6): 4-11
Orman and Mattu in Herbert (2015) EM:Rap 15(7): 1-2
Pacheco and Rawani-Patel (2019) Crit Dec Emerg Med 33(5): 3-11
Swaminathan and Mattu in Herbert (2020) EM:Rap 20(9): 9-10
Chiabrando (2020) J Am Coll Cardiol 75(1):76-92 [PubMed]
Imazio (2007) Int J Cardiol 118(3): 286-94 [PubMed]
Lange (2004) N Engl J Med 351:2195-202 [PubMed]
LeWinter (2014) N Engl J Med 371(25): 2410-6 +PMID:25517707 [PubMed]
Peterson (2024) Am Fam Physician 109(5): 441-6 [PubMed]
Synder (2014) Am Fam Physician 89(7): 553-60 [PubMed]
Tingle (2007) Am Fam Physician 76: 1509-14 [PubMed]
Troughton (2004) Lancet 363: 717-27 [PubMed]