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% | *Infection (up to 20%) | ||
*Malignancy | **[[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: [[ | *Drugs: | ||
*Cardiac injury (can see up to weeks later) | **[[Procainamide]] | ||
* | **[[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]] | ||
** | **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, | **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 ( | **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 segments return to baseline | |||
**Large T waves | |||
**PR depression | |||
*Stage III: | *Stage III: | ||
**T wave | **T wave flattening progressing to inversion | ||
*Stage IV: | *Stage IV: | ||
**Return to baseline | **Return to baseline | ||
{{STEMI vs pericarditis}} | |||
==Management== | ==Management== | ||
===Initial Treatment=== | ===Initial Treatment=== | ||
*'''NSAIDS or Aspirin | *'''[[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 | ''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 | **Patients >70kg - 0.6mg PO BID x 6 months | ||
**Patients<70kg - 0.6mg PO Daily x | **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 [[ | *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 | ||
* | *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]] | ||
==References== | ==References== |
Revision as of 14:04, 22 May 2020
Background
- Inflammation of the pericardium
Etiology
- Idiopathic (25-85%)
- Infection (up to 20%)
- Malignancy
- Hematologic
- Lung
- Breast
- Primary cancers of the pericardium are rare but potential causes
- Uremia
- Chronic kidney failure
- Post radiation
- Connective tissue disease or other autoimmune conditions
- Drugs:
- Procainamide
- 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
- Pleuritic chest pain
- Radiates to chest, back, left trapezius
- Diminishes with sitting up/leaning forward
- Shortness of breath
- Especially if concommitant pleural effusion
- Hypotension/extremis if cardiac tamponade
- Fever, chills, myalgias (systemic signs with viral infection)
- 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
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
- WBC, CMP, ESR, CRP
- Consider TSH, ANA based on clinical suspicion
- Troponin elevation may indicate a concurrent myocarditis which predispose to risk of CHF or arrhythmia. [2]
- 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
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
- 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]
- TWI don't invert in pericarditis until STE resolved; if TWI and STE simultaneously present, more likely ACS/MI
Stages of Progression
- 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]
- 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
- 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
- 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
- ↑ Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA 2015;314(14):1498–506.
- ↑ LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
- ↑ LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. doi: 10.1056/NEJMcp1404070. Review.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
- ↑ ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.
- ↑ 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