Pericarditis

Introduction

  • Inflammation of the pericardium.
  • 90% of cases are idiopathic or related to viral infections.
  • Complications can include developing pericardial effusion, tamponade, and constriction. 
  • Treatment generally with ASA/NSAIDS and Colchicine.

Etiologies

  • Idiopathic (most common as exact cause is usually not identified)
  • Infections:
    • Viral: Echovirus, Adenovirus, Coxsackievirus, CMV, EBV, Parvovirus, Influenza, HIV
    • Bacterial: (similar to lung infections, can also be from extension of primary lung infection) Staph, Strep, Pneumococcus, Haemophilus, Mycoplasma, Legionella, Gonococcus
    • Fungal: Coccidiodomycosis, Histoplasmosis
    • Mycobacterium: Tuberculosis, Avium.
    • Parasites: Toxoplasmosis, Echinococcosis
  • Neoplastic:
    • Primary: Angiosarcoma, Mesothelioma, Paraganglioma, Lipoma
    • Secondary: Lung, Breast, Lymphoma, GI, Melanoma, Kaposi Sarcoma,
  • Inflammatory:
    • Myocarditis
    • Collagen diseases: Lupus, Rheumatoid Arthritis, Scleroderma, Sjogren’s
    • Vasculitis: Giant Cell Arteritis, Churg-Strauss, Polyarteritis Nodosa
    • Rheumatic Fever
    • Inflammatory Bowel Disease
    • Sarcoidosis
    • Medications: Hydralazine, Procainamide, Doxorubicin, Cyclosporine, Cyclophosphamide
  • Radiation
  • Trauma
  • Post-Myocardial Infarction
  • Congenital: absence of pericardium
  • Renal failure (Uremia)

Diagnosis

Clinical Presentation

  • Pleuritic retrosternal chest pain.
  • Pain often radiates to back or trapezius.
  • Pain is worse when lying flat and relieved by siting forward.
  • Associated symptoms include, dyspnea, fever, tachycardia, and occasionally signs of tamponade.
  • Pericardial friction rub “classic/pathognomonic” finding, best heard with the patient sitting forward on end expiration

Diagnosis confirmed if 2 out of 4 classic features 

  • 1) Classic pleuritic chest pain that is positional.
  • 2) Typical ECG changes.
  • 3) Pericardial friction rub.
  • 4) Pericardial effusion.

Investigations

  • Standard bloodwork: CBC, lytes, urea, creatinine, liver enzymes.
  • Troponin (If positive consider myopericarditis or prior myocardial infarction).
  • CRP (Confirm inflammatory process, most patients with pericarditis will have an elevated CRP. Therefore, helpful test to rule out pericarditis if negative. Also useful for tracking response to treatment).
  • ECG
  • ECHO
  • Consider: Autoimmune work-up (ANA, ANCA, RF), HIV, HCV, TSH, malignancy work-up, if clinical suspicion.

ECG (4 Phases)

  1. Diffuse ST elevation (upsloping/concave), with PR depression, and reciprocal changes in aVR.
  2. Normalization of ST segments
  3. T-wave inversions
  4. T-wave normalization

Echo

  • Looking for pericardial effusion as most patients will have this in pericarditis.
  • Must rule out cardiac tamponade clinically (echocardiogram can be helpful)
  • Pericardiocentesis is rarely required unless there is tamponade physiology, suspected bacterial or malignant cause.

Patient Triage

  • If any predictors of poor prognosis are present or if no response to NSAIDS, patient should be admitted and search for etiology
  • Consider POCUS for patients to assess for large effusion before discharge

Treatment

  1. High dose NSAID’s (ie. Ibuprofen 600-800mg QID) or ASA (650mg QID) for 1-2 weeks.
  2. Colchicine 0.5mg bid or if less than 70kg 0.5mg daily for 3 months (decreases recurrence).
  3. Low dose corticosteroids (ie. 0.2-0.5mg/kg/day) can be used with failure/contraindication to ASA/NSAIDS with colchicine or with autoimmune etiology.
  4. Proton Pump Inhibitor while on high dose NSAIDS/ASA.

Further Reading

  • Primary Author: Dr. Daniel Durocher (MD, FRCPC, Cardiology Fellow)
  • Author/Reviewer: Dr. Atul Jaidka (MD, FRCPC, Cardiology Fellow), Dr. Pavel Antiperovitch (MD, FRCPC)
  • Staff Reviewer: Pending
  • Last Updated: March 22, 2020
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