Pericarditis

Background

Etiology

1. Idiopathic (25-85%)
2. Infection (up to 20%, including viral, bacterial, TB)
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

Clinical Features

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

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression

• ECG
  • Less reliable in post-MI pts and those w/ baseline ECG abnormalities
  • May see low voltage/alternans if effusion present
  • If early repol confounding interpretation check ST:T ratio
    • If (ST elev)/(T height) in V6 or I >0.25 likely pericarditis

Stages of Progression

Stages of pericarditis

PTa depression

• Stage I:
  • Global concave up ST elevation in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
  • PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
• Stage II:
  • "pseudonormalisation," ST to baseline, big T's, PR dep
• Stage III:
  • T wave flatten then inversion
• Stage IV:
  • Return to baseline

Work-Up

• ECG
• Labs
  • WBC, ESR, trop
• CXR
• Bedside Ultrasound to r/o effusion

Differential Diagnosis

• STEMI
• CHF
• PE
• Pneumothorax
• Aortic dissection
• Pneumomediastinum
• Pleuritis

STEMI vs Pericarditis

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

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Treatment

1. NSAIDS for viral/idiopathic
2. Recurrent - colchicine
3. Uremic - dialysis
4. Tamponade --> Pericardiocentesis

Disposition

1. Hospitalization is not necessary in most cases
2. Consider admission for:
   1. Subacute onset over weeks
   2. Fever >100.4
   3. Large effusion (echo-free space>20mm)
   4. Immunosupressed
   5. Anticoagulant use
   6. Failure to respond to NSAID Rx (>7dy)

Complications

1. Pericardial Effusion and Tamponade
2. Recurence
   1. Usually weeks to months after initial episode
   2. Management is same
3. Contrictive Pericarditis
   1. Restrictive picture with pericardial calcifications on CXR, thickened on TTE
   2. Rx with pericardial window

Source

Tintinalli, UpToDate

See Also

• ST segment elevation