Pericarditis

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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 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

Initial Treatment

  1. NSAIDS Aspirin (ASA)are usual first line treatment for viral or idiopathic pericarditis. Two options both have tapering doses:[1]
    1. Aspirin 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    2. Ibuprofen 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  2. Glucocorticoid therapy for patients contraindications to NSAIDS
    1. Prednisone 0.2 to 0.5 mg/kg of body weight per day for 2 weeks with gradual tapering[2]

Recurrent or Refractory

For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[3]

  1. Colchicine
  2. Patients >70kg - 0.6mg PO BID x3months
  3. Patients<70kg - 0.6mg PO Daily x 3 months
    • If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

Contraindications to Colchicine[4]

  • Tuberculous
  • Neoplastic pericarditis
  • Liver disease or aminotransferase levels ≥1.5x upper limits of normal
  • Creatinine >2.5 mg/dL (>221 umol/L)
  • Myopathy or CK > upper limits of normal
  • Inflammatory bowel disease
  • Life expectancy ≤18 months
  • Pregnancy or lactation

Uremic Pericarditis

The definitive treatment is dialysis

Tamponade

  1. Tamponade requires 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

See Also

Sources

  1. ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
  2. ↑ Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.
  3. ↑ Imazio M.Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91.
  4. ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF
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