Pericarditis: Difference between revisions

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==Background==
==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
*Inflammation of the pericardium
===Etiology===
===Etiology===
*Idiopathic (25-85%)
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Infection (up to 20%)
*Malignancy: heme, lung, breast
**[[Viral syndrome|Viral]]
**[[Bacterial disease|Bacterial]]
**[[TB]]
**[[HIV]]
*Malignancy
**Hematologic
**Lung
**Breast
**Primary cancers of the pericardium are rare but potential causes
*[[Uremia]]
*[[Uremia]]
**Chronic [[renal failure|kidney failure]]
*Post radiation
*Post radiation
*Connective tissue disease
*[[Connective tissue disease]] or other autoimmune conditions
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Drugs:  
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
**[[Procainamide]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>
**[[Hydralazine]]
**Methyldopa
**[[Phenytoin]]
**[[Anticoagulants]] (especially warfarin and heparin)
*Cardiac injury (can see up to weeks later)
**Post [[MI]] (Dressler's syndrome)
**[[Thoracic trauma]]
**[[Aortic dissection]]
**Cardiac surgery


==Clinical Features==
==Clinical Features==
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**Radiates to chest, back, left trapezius
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
*[[Shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
**Especially if concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub
*Friction rub


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==Evaluation==
==Evaluation==
===Diagnostic Criteria for Acute Pericarditis<ref>Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA 2015;314(14):1498–506.</ref>===
*Need 2 of the following
**Chest pain (typically sharp and pleuritic, improved by sitting up and leaning forward)
**Pericardial friction rub
**New or worsening pericardial effusion
**Suggestive ECG changes
===Work-Up===
===Work-Up===
*ECG
*[[ECG]]
*Labs
*Labs
**WBC, ESR, trop
**WBC, CMP, ESR, CRP
*CXR
**Consider TSH, ANA based on clinical suspicion
**[[Troponin]] elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Bedside Ultrasound to rule out effusion
**~2/3 of cases will have pericardial effusion<ref>LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. doi: 10.1056/NEJMcp1404070. Review. </ref>
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists


===ECG===
===ECG===
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**STE II > STE III favors pericarditis
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>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.</ref>
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>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.</ref>
*Spodick's sign, purportedly in ~80% - downsloping TP segment, often best seen in lead II and lateral precordial leads<ref>Chaubey VK and Chhabra L. Spodick’s Sign: A Helpful Electrocardiographic Clue to the Diagnosis of Acute Pericarditis. Perm J. 2014 Winter; 18(1): e122.</ref>
[[File:ST-T ratio.jpg|thumbnail]]
[[File:Spodick's_sign.JPG|thumbnail|Spodick's sign]]
*TWI don't invert in pericarditis until STE resolved; if TWI and STE simultaneously present, more likely ACS/MI


====Stages of Progression====
====Stages of Progression====
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[[File:Ptadepressie.png|thumb|PTa depression]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:   
*Stage I:   
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**Global concave up [[ST elevation]] in all leads (especially V4-6, I, II) except aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)  
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)  
*Stage II:   
*Stage II:   
**"pseudonormalisation," ST to baseline, big T's, PR dep
**"Pseudonormalisation"  
**ST segments return to baseline
**Large T waves
**PR depression
*Stage III:   
*Stage III:   
**T wave flatten then inversion
**T wave flattening progressing to inversion
*Stage IV:   
*Stage IV:   
**Return to baseline
**Return to baseline


===[[STEMI]] vs [[Pericarditis]]===
{{STEMI vs pericarditis}}
{| class="wikitable"
|-
| '''[[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
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}


==Management==
==Management==
===Initial Treatment===
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)''' are usually first line treatment for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
*'''[[NSAIDS]] or [[Aspirin]]: '''first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks  OR
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks  '''OR'''
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Glucocorticoid therapy''' for patients with contraindications to [[NSAIDs]]
*'''[[Colchicine]]''' add to [[NSAIDs]] as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''[[Glucocorticoid]] therapy''' second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to [[NSAIDs]] or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week.  Also used for etiologies that are steroid responsive diseases.
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>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.</ref>
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>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.</ref>


===Recurrent or Refractory===
===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>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.</ref>
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.Colchicine as first-choice therapy for recurrent pericarditis: results of the C'''OR'''E (Colchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91.</ref>


*'''[[Colchicine]]'''
*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 3 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.


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===[[Pericardial effusion and tamponade|Tamponade]]===
===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires  [[Pericardiocentesis]]
*Tamponade requires  [[pericardiocentesis]]


==Disposition==
==Disposition==
*Hospitalization is not necessary in most cases  
*Hospitalization is not necessary in most cases  
*Consider admission for:
*Consider admission for:
**Patients likely to have a specific cause (i.e. uremia, malignancy)
**Subacute onset over weeks
**Subacute onset over weeks
**[[Fever]] >100.4
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Large effusion (echo-free space>20mm)
**Cardiac tamponade
**Immunosupressed
**Immunosupressed
**Anticoagulant use
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes
**Elevated cardiac enzymes (suggesting myopericarditis)
**Trauma


==Complications==
==Complications==
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**Usually weeks to months after initial episode
**Usually weeks to months after initial episode
**Management is same
**Management is same
*Contrictive Pericarditis
*Constrictive Pericarditis
**Related to etiology; increased risk with bacterial pericarditis, rare with viral/idiopathic etiology
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window
**Treat with pericardial window
==External Links==
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]
*[https://journalfeed.org/article-a-day/2020/differentiating-stemi-from-pericarditis Differentiating STEMI from Pericarditis.]


==See Also==
==See Also==
*[[ST segment elevation]]
*[[ST segment elevation]]
*[[STEMI]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[[Myocardial infarction complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]


==References==
==References==

Revision as of 14:04, 22 May 2020

Background

Pericarditis compared with normal pericardium
  • Inflammation of the pericardium

Etiology

Clinical Features

Differential Diagnosis

ST Elevation

Evaluation

Diagnostic Criteria for Acute Pericarditis[1]

  • Need 2 of the following
    • Chest pain (typically sharp and pleuritic, improved by sitting up and leaning forward)
    • Pericardial friction rub
    • New or worsening pericardial effusion
    • Suggestive ECG changes

Work-Up

  • ECG
  • Labs
  • CXR
  • Bedside Ultrasound to rule out effusion
    • ~2/3 of cases will have pericardial effusion[3]
  • Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression

Classical Teachings with Caveats Below

  • Must differentiate from STEMI (classical teachings are not specific enough to do that)
  • Classically pericarditis has diffuse ST-elevations
    • However, pericarditis may generate localized ST-elevations
    • Pericarditis should never produce ST-depressions (suggestive of reciprocal changes), except in V1 and aVR
  • Classically pericardidits has concave upwards STE
    • However, STEMI may have concave upwards ST-segment morphology as well
    • Rather, it is STE convex upwards or horizontal that favors STEMI
  • Classically pericardititis has PR-depression in viral pericarditis (or PR-elevation in AVR)
    • Less reliable in post-MI patients and those with baseline ECG abnormalities
    • PR-depression is often early and transient in pericarditis
    • In STEMI, PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis[4]
    • PR-elevation in aVR may also be present in STEMI and is infrequently seen in constrictive pericarditis

Other Findings

  • Leads II and III
    • STE II > STE III favors pericarditis
    • STE III > STE II very strongly favors STEMI
  • STD not in aVR or V1 (reciprocol changes) suggestive of STEMI
  • May see low voltage/alternans if effusion present
  • If early repolarization confounding interpretation check ST:T ratio
    • If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
  • If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI[5]
  • Spodick's sign, purportedly in ~80% - downsloping TP segment, often best seen in lead II and lateral precordial leads[6]
ST-T ratio.jpg
Spodick's sign
  • TWI don't invert in pericarditis until STE resolved; if TWI and STE simultaneously present, more likely ACS/MI

Stages of Progression

Stages of pericarditis
PTa depression
  • Stage I:
    • Global concave up ST elevation in all leads (especially V4-6, I, II) except 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 segments return to baseline
    • Large T waves
    • PR depression
  • Stage III:
    • T wave flattening progressing to inversion
  • Stage IV:
    • Return to baseline

STEMI vs Pericarditis

Disease STEMI Pericarditis
Pain Constant Varies with motion
Fever No Yes
ST changes focal Diffuse elevation
Reciprocal changes Yes No
Q waves Yes No
Pulmonary edema Sometimes No
Wall motion Abnormal Normal

Management

Initial Treatment

  • NSAIDS or Aspirin: first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.[7]
    • Aspirin 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    • Ibuprofen 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  • Colchicine add to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.[8]
    • Patients >70kg - 0.6mg PO BID x 3 months
    • Patients<70kg - 0.6mg PO Daily x 3 months
  • Glucocorticoid therapy second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to NSAIDs or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week. Also used for etiologies that are steroid responsive diseases.
    • Prednisone 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering[9]

Recurrent or Refractory

For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[10]

  • Colchicine
    • Patients >70kg - 0.6mg PO BID x 6 months
    • Patients<70kg - 0.6mg PO Daily x 6 months
    • If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

Contraindications to Colchicine[11]

  • 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

Disposition

  • Hospitalization is not necessary in most cases
  • Consider admission for:
    • Patients likely to have a specific cause (i.e. uremia, malignancy)
    • Subacute onset over weeks
    • Fever >100.4
    • Large effusion (echo-free space>20mm)
    • Cardiac tamponade
    • Immunosupressed
    • Anticoagulant use
    • Failure to respond to NSAIDs (>7dy)
    • Elevated cardiac enzymes (suggesting myopericarditis)
    • Trauma

Complications

  • Pericardial Effusion and Tamponade
  • Recurence
    • Usually weeks to months after initial episode
    • Management is same
  • Constrictive Pericarditis
    • Related to etiology; increased risk with bacterial pericarditis, rare with viral/idiopathic etiology
    • Restrictive picture with pericardial calcifications on CXR, thickened on TTE
    • Treat with pericardial window

External Links

See Also

References

  1. ↑ Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA 2015;314(14):1498–506.
  2. ↑ LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
  3. ↑ LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. doi: 10.1056/NEJMcp1404070. Review.
  4. ↑ Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.
  5. ↑ 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.
  6. ↑ Chaubey VK and Chhabra L. Spodick’s Sign: A Helpful Electrocardiographic Clue to the Diagnosis of Acute Pericarditis. Perm J. 2014 Winter; 18(1): e122.
  7. ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
  8. ↑ ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF
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