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, hydralazine, methyldopa, anticoagulants
  8. Cardiac injury (can see up to weeks later): post MI (Dressler's syndrome), trauma, aortic dissection

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

Differential Diagnosis

Diagnosis

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression
  • ECG
    • Classically described to cause diffuse ST elevations
    • 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

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

Management

Initial Treatment

  • NSAIDS or Aspirin (ASA) are usually first line treatment for viral or idiopathic pericarditis.[1]
    • Aspirin 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    • Ibuprofen 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  • Glucocorticoid therapy for patients contraindications to NSAIDs
    • 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]

  • Colchicine
    • Patients >70kg - 0.6mg PO BID x3months
    • 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

Disposition

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

Complications

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

See Also

References

  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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