Pericarditis
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Background
Etiology
- Idiopathic (25-85%)
- Infection (up to 20%, including viral, bacterial, TB)
- Malignancy: heme, lung, breast
- Uremia
- Post radiation
- Connective tissue disease
- Drugs: procainamide, hydralazine, methyldopa, anticoagulants
- Cardiac injury (can see up to weeks later): post MI (Dressler's syndrome), thoracic trauma, aortic dissection
- Troponin elevation may indicate a concurrent myocarditis which predispose to risk of CHF or arrhythmia. [1]
Clinical Features
- Pleuritic chest pain
- Radiates to chest, back, left trapezius
- Diminishes with sitting up/leaning forward
- SOB
- Esp if concommitant pleural effusion
- Hypotension/extremis if cardiac tamponade
- Fever
- Friction rub
Differential Diagnosis
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
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Evaluation
Work-Up
- ECG
- Labs
- WBC, ESR, trop
- CXR
- Bedside Ultrasound to rule out effusion
ECG
- Classically described to cause diffuse ST elevations
- Less reliable in post-MI patients and those with 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
- If predominantly inferior elevation, depression in aVL is sensitive for STEMI[2]
Stages of Progression
- 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
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 |
Management
Initial Treatment
- NSAIDS or Aspirin (ASA) are usually first line treatment for viral or idiopathic pericarditis.[3]
- Glucocorticoid therapy for patients with contraindications to NSAIDs
- Prednisone 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering[4]
Recurrent or Refractory
For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[5]
- Colchicine
- Patients >70kg - 0.6mg PO BID x 3 months
- 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[6]
- Tuberculous
- Neoplastic pericarditis
- Liver disease or aminotransferase levels ≥1.5x upper limits of normal
- Creatinine >2.5mg/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
- Tamponade requires Pericardiocentesis
Disposition
- Hospitalization is not necessary in most cases
- Consider admission for:
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
- ↑ LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
- ↑ Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.
- ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
- ↑ 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.
- ↑ 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.
- ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF