Pericarditis

Etiology

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

Workup

• ECG
  • Less reliable in post-MI pts, 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 >0.25 likely pericarditis
  • 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
• Labs
  • WBC, ESR, trop all nonspecific
• CXR
  • If increased cardiac silhouette seen consider effusion

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

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 Echo
   2. Rx with pericardial window

Source

UpToDate