Pericarditis

Background

Causes:

1. Idiopathic
2. Infection
3. Malignancy: heme, lung, breast
4. Uremia
5. Post radiation
6. Connective tissue dz
7. Drugs: procainamide, hydralaine, methyldopa, anticoagulants
8. Cardiac injury (can see up to weeks later): post MI, trauma, aortic dissection

Diagnosis

1. Pleuritic chest pain
   1. Radiates to chest, back, trapezius
   2. Diminishes w/ sitting up/leaning forward
2. SOB
   1. Esp if concommitant pleural effusion
3. Hypotension/extremis if tamponade
4. Friction rub

Workup

ECG

• Less reliable in post MI pts and those w/ baseline ECG abnormalities
• If pt has early repol confounding interpretation check (ST elev)/(T height) in V6
  • if >0.25 likely pericarditis

ECG progression:

1. Global concave up ST elev, +/- PR depression
2. ST to baseline, big T's, PR dep
3. T wave flatten then inversion
4. Return to baseline EKG

• CXR, WBC, ESR, Trop all nonspecific

DDX

MI	Pericarditis
no fever	fever pain varies w/motion
focal ST chgs	diffuse ST elev
reciprocal chgs	no reciprocal chgs
Q waves	no Q wave
+/- pulm edema	clear lungs
wall motion abn	nl wall motion

• CHF
• PE
• PTX
• Aortic dissection
• Pneumomediastinum
• pleuritis

Treatment

1. Mostly supportive
2. NSAIDS for viral/idiopathic
3. Recurrent - colchicine
4. Uremic - dialysis
5. "buy time" with fluid boluses
6. Tamponade --> Pericardiocentesis

Disposition

1. Most need admission, but if young and healthy can echo, and D/C with close f/u

Risk Stratification

HIGH RISK (admit)

1. Subacute sx (several dys-wks)
2. Fever >100.4
3. Evidence of tamponade
4. Large effusion (>20mm)
5. Immunosupressed
6. On anticoagulant
7. Acute trauma
8. Failure to respond to NSAID Rx (>7dy)

Complications

Tamponade/Effusion-see Pericardial Effusion and Tamponade

Recurrence

1. usually weeks to months after initial episode
2. management is same

Contrictive Pericarditis

1. restrictive picture with pericardial calcific on CXR and thicken on ECHO
2. Rx window

Source

Adapted from Pani, Donaldson, and UpToDate