Diagnosis:
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Chest pain consistent with pericarditis (sharp, worse with laying flat and inspiration, better sitting up), 80-90%
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Pericardial friction rub (high pitched, scratchy , left sternal border), <33%
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Typical ECG changes , 60%
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Pericardial effusion , 60%
ECG findings:
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ST elevation in multiple leads
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PR depression (not diagnostic of pericarditis, can occur in MI)
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Absence of reciprocal ST depression (exception V1 and aVR may show ST depression and PR elevation)
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Progression over days is classically taught as:
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ST elevation with PR depression
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Normalization of ST and PR segments
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Inversion of T waves
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Normalization of all segments
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Testing:
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ECG
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CBC with diff
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High sensitivity CRP
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ESR
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Troponin – elevated in 15-25%, at higher risk of CHF or arrhythmia.
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Creatinine
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LFTs
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Chest X-ray
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Echocardiogram to r/o large effusion
Causes:
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Viruses (most common)
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Bacterial Infection
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Fungal Infections
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Trauma
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Subacute MI
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Tuberculosis
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HIV/AIDS
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Renal Failure
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Radiation Therapy
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Lupus
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Rheumatoid Arthritis
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Malignancy
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Medications: Phenytoin, Warfarin, Heparin, Procainamide
Treatment:
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NSAIDs + PPI (1st time or recurrence)
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Ibuprofen 600 mg every 8 hours x 1-2 weeks, then decrees by 200-400 mg every 2 weeks
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Aspirin 750-100 mg every 8 hours x 1-2 weeks, then decrease by 250-500 mg every 2 weeks (utilized in Europe)
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- Colchicine (in addition to NSAIDS) decreases duration and likelihood of recurrence if taken for 3 months*
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0.5 mg BID if weight >70kg
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0.5 mg Daily if weight <70kg
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Steroids not recommended as first line agent. Only use if NSAIDs contraindicated. Low dose prednisone 0.2–0.5 mg/kg/day or equivalent is recommended. *
Disposition:
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Good prognosis, may be discharged with at least 1 week follow up:
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Afebrile
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Not immunocompromised
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No hx of trauma
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No evidence of myocarditis
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No large pericardial effusion
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Not anticoagulated
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- Poor prognosis, admission recommended if at least one major criterion present:
- Fever
- Subacute course- no clear sudden onset
- Large Effusion (diastolic free space >20mm on echo)
- Cardiac Tamponade
- No response to NSAIDS within 7 days
- Immunosuppressed (minor)
- Anticoagulated (minor)
- Trauma (minor)
- Myocarditis (minor)
Source: https://academic.oup.com/view-large/figure/108776039/ehv31801.tif
Prognosis:
“Most patients with acute pericarditis (generally those with presumed viral or idiopathic pericarditis) have a good long-term prognosis.Cardiac tamponade rarely occurs in patients with acute idiopathic pericarditis, and is more common in patients with a specific underlying aetiology such as malignancy, TB or purulent pericarditis. Constrictive pericarditis may occur in <1% of patients with acute idiopathic pericarditis, and is also more common in patients with a specific aetiology. The risk of developing constriction can be classified as low (<1%) for idiopathic and presumed viral pericarditis; intermediate (2–5%) for autoimmune, immune-mediated and neoplastic aetiologies; and high (20–30%) for bacterial aetiologies, especially with TB and purulent pericarditis.36 Approximately 15–30% of patients with idiopathic acute pericarditis who are not treated with colchicine will develop either recurrent or incessant disease, while colchicine may halve the recurrence rate.”
Notes:
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Other definitions:
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Incessant Pericarditis: Symptoms for > 4-6 weeks but < 3months without remission
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Recurrent Pericarditis: Symptom free 4-6 weeks before recurrence.
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Chronic: Symptoms lasting > 3months
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References:
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Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-64. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29.
