Pericardium
Pericarditis
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Pericarditis
, Acute Pericarditis, Viral Pericarditis, Infectious Pericarditis
See Also
Pericardial Effusion
Pericarditis Causes
EKG in Pericarditis
Medication Causes of Pericarditis
Epidemiology
Accounts for 5% of Emergency Department
Chest Pain
cases
Most typical patient is a male aged 20 to 50 years old
However occurs in both genders and at all ages
Pathophysiology
Pericardial Layers
Parietal
Pericardium
Surrounds heart and limits end diastolic heart volume
Closely adhered to the
Great Vessel
s and has minimal elasticity
Pericardial sac
Between the two pericardial layers
Typically contains less than 30 cc fluid (15-50 ml)
Visceral
Pericardium
(epicardium)
Delicate lining surrounding heart and
Great Vessel
s
Etiology
See
Pericarditis Causes
Symptoms
Exercise
intolerance
Fatigue
Prodrome (if infectious)
Fever
Malaise
Myalgias
Symptoms
Chest Pain
Pleuritic Chest Pain
occurs in 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
Ridge of trapezius (inferior
Scapula
r pole) due to left phrenic nerve irritation (Very specific for Pericarditis)
Neck, Jaw or
Shoulder
(similar to
Myocardial Infarction
radiation)
Modifying Factors
Not relieved with
Nitroglycerin
Pleuritic Chest Pain
Provoked by
Swallowing
, inspiration, cough
Positional
Worse while lying down supine
Better while sitting, leaning forward
Precaution
Acute
Myocardial Infarction
may present with positional
Pleuritic Chest Pain
in 16% of cases
Acute
Myocardial Infarction
may also present with Pericarditis
Signs
Fever
(if infectious)
Fever
>101.3 F (38.5 C) may suggest more significant infection (e.g.
Tuberculosis
,
Bacterial Infection
)
Sinus Tachycardia
Pericardial Friction Rub
(pathognomonic for Pericarditis)
Uncommonly heard in Pericarditis despite reported occurring in up to 85% of cases (typically transient)
High-pitched scratchy, squeeking or crunch sound of walking on snow
Auscultate left sternal border or mid-clavicular line at second to fourth intercostal spaces
Patient leaning forward and holding breath (distinguishes from pleural rub)
Unlikely to be heard if
Pericardial Effusion
present
Distant heart sounds
Tamponade signs
Kussmaul's Sign
Pulsus paradoxicus
Jugular Venous Distention
Associated
Myocarditis
findings
See
Myocarditis
Children may present with more subtle findings (e.g.
Puffy Eyelid
s,
Sinus Tachycardia
)
Labs
Initial
Serum
Electrolyte
s
Serum
Troponin I
(or other
Cardiac Marker
s)
Troponin I
increased in 15-25% of cases (resolving after 7-14 days)
Significant
Troponin I
ncreases are more suggestive of
Myocarditis
(or
Acute Coronary Syndrome
)
Myocarditis
is associated with increased risk of CHF or
Arrhythmia
Mild
Troponin
elevation may be seen with Pericarditis
Mildly increased
Troponin
does not appear to confer overall adverse outcome in Pericarditis
Acute phase reactants increased
Complete Blood Count
(CBC)
Erythrocyte Sedimentation Rate
(ESR)
C-Reactive Protein
(CRP)
Increased in 76% of Pericarditis cases
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
Exclude
Myocardial Infarction
first
Overdiagnosis and misdiagnosis of Pericarditis instead of true
STEMI
is most significant pitfall
Obtain serial EKGs
EKG in
Myocardial Infarction
evolves over minutes to hours
EKG in Pericarditis
evolves over days
Imaging
Chest XRay
Useful in ruling out
Pneumonia
or
Pneumothorax
May identify underlying cause (e.g.
Tuberculosis
,
Lung Cancer
)
Rarely diagnostic for Pericarditis
Pleural Effusion
in 50% of cases
Enlarged cardiac silhouette (water bottle heart)
Difficult to identify (Compare with old films)
Present only if
Pericardial Effusion
>250 ml
MRI chest or CT chest
Consider in inconclusive cases or evaluation for purulent Pericarditis (e.g.
Staphylococcus aureus
)
Imaging
Echocardiogram
Indications
Recommended in all Pericarditis cases to evaluate for
Pericardial Effusion
and estimate ejection fraction
Preferred Imaging technique indicated for signs of
Cardiac Tamponade
(Increased JVP or
Pulsus Paradoxus
)
Identifies
Pericardial Effusion
and
Cardiac Tamponade
Findings
Pericardial Effusion
s are present in 60% of Pericarditis cases (with most being small effusions, <1 cm wide)
Echocardiogram
is also used to evaluate ejection fraction
Precautions
Does not rule out Pericarditis if normal (May be normal in Pericarditis)
Effusion grading
Mild effusion: <1 cm wide
Moderate effusion: 1-2 cm wide
Large
Pericardial Effusion
: 2-2.5 cm wide
Very large
Pericardial Effusion
: >2.5 cm wide
Diagnosis
Requires 2 of the following 4 criteria
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
Complications
Pericardial Effusion
(60% of cases)
See
Echocardiogram
above
Serous effusion: Viral Pericarditis
Exudative effusion: Neoplastic,
Tuberculosis
and
Bacteria
l Pericarditis
Cardiac Tamponade
Uncommon in Viral Pericarditis or idiopathic Pericarditis (5-15%)
Occurs in 60% of exudative cases listed above
Constrictive Pericarditis
Evaluation
Severe Pericarditis predictive factors
Major criteria
Fever
>100.4 F (38 C)
Subacute onset
Cardiac Tamponade
findings
Large
Pericardial Effusion
(>2 cm wide)
Failed
NSAID
s for 7 days
Minor criteria
Immunocompromised
Oral
Anticoagulant
s
Pericarditis due to acute
Trauma
Troponin I
ncreased (possible myopericarditis)
Management
Disposition
Hospitalization Indications
Anticoagulation
therapy
Fever
>100.4 F
Large
Pleural Effusion
by
Echocardiogram
(>2 cm wide)
Cardiac Tamponade
Immunocompromised
Status
Trauma
tic 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
Management
Medications
Preacaution: Post-
Myocardial Infarction
Pericarditis
Aspirin
is first-line therapy for post-
Myocardial Infarction
Pericarditis (or Pericarditis and known
Coronary Artery Disease
)
Aspirin
650-1000 mg every 6-8 hours for 7-10 days and then tapered over 4 weeks
NSAID
s and
Corticosteroid
s are contraindicated in post-MI Pericarditis
NSAID
s and
Corticosteroid
s delay healing
Non-
Myocardial Infarction
related Pericarditis
Consider adjusting medication protocol and dosing based on acute phase reactant levels
Consider concurrent GI prophylaxis with
Proton Pump Inhibitor
(e.g.
Omeprazole
)
First line:
NSAID
s for 2-4 weeks
Ibuprofen
600 to 800 mg every 6-8 hours tapered over 4 weeks
Indomethacin
25-50 mg three times daily tapered over 4 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)
See
Colchicine
for adverse effects and lab monitoring
Colchicine
weaned after CRP drops to <3
Weight > 70 kg (154 lb): 0.5 mg twice daily
Weight <70 kg (154 lb): 0.5 mg once daily
Significantly reduces Pericarditis episode duration and recurrence rate
Imazio (2005) Circulation 112: 2012-6 [PubMed]
Imazio (2013) N Engl J Med 369(16): 1522-8 [PubMed]
Refractory cases:
Prednisone
10 mg PO qd x1-2 weeks
Avoid in most cases
Increased risk of recurrence, especially in Viral Pericarditis (
Odds Ratio
>4)
Indications
Connective Tissue Disease
or
Autoimmune Condition
Uremic Pericarditis
Refractory to
NSAID
s and
Colchicine
Protocol
Prednisone
1 mg/kg/day tapering to 0.25 mg/kg/day and then to
NSAID
s over 6-8 weeks
Taper to
NSAID
s and/or
Colchicine
Antimicrobial agents (rarely indicated)
Antibiotics for
Bacteria
l Pericarditis
Antifungal
s for fungal Pericarditis
Lyme Disease
Tuberculosis
Trypansoma cruzi
Management
Infectious Pericarditis
Uncommon (most cases are inflammatory - see above)
Purulent
Bacteria
l Pericarditis
Typically empiric antibiotics, then guided by
Pericardiocentesis
fluid culture and sensitivity
First-line antibiotics
Vancomycin
15-20 mg/kg IV every 8-12 hours AND
Ceftriaxone
2 g IV every 24 hours OR
Cefepime
2 g IV every 12 hours
Alternative regimen
Vancomycin
15-20 mg/kg IV every 8-12 hours AND
Ciprofloxacin
750 mg orally twice daily OR 400 mg IV twice daily
Other infectious causes (consult infectious disease)
Histoplasmosis
(mild cases may be treated as inflammatory Pericarditis, WITHOUT
Antifungal
s)
Tuberculosis
References
(2016) Sanford Guide, accessed 4/8/2016
Management
Gene
ral
Gene
ral measures
Head of bed elevated
Humidified
Supplemental Oxygen
Cardiac monitor
Pulse Oximetry
Intravenous Access
Emergent management for
Unstable Patient
Initial:
Pericardiocentesis
by experienced clinician
Refractory: Subxiphoid pericardial drainage and biopsy with histology and culture
Pericardiocentesis
Indications
Suspected
Bacteria
l Pericarditis
Cardiac Tamponade
Course
Symptoms typically subsides within 2 weeks
Recurrence in 15% in a few months after initial episode
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
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]
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]
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