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{{Pericarditis}}
{{Pericarditis}}
{{CMG}}; {{AE}}[[Varun Kumar, M.B.B.S.]]{{Homa}}


{{CMG}}
==Overview==
Non-specific markers of [[inflammation]] are generally elevated in [[pericarditis]]. These include the [[leukocyte]] count, [[C-reactive protein]], and [[ESR]]. The [[cardiac troponin]] is elevated if there is an injury to the underlying [[myocardium]], a condition termed as myopericarditis. Diagnostic [[pericardiocentesis]] and [[biopsy]] help in identifying an underlying infectious or malignant process.


==Inflammatory markers==
==Inflammatory Markers==
*The [[Complete Blood Count|CBC]] may show an elevated white count and a serum [[C-reactive protein]] may be elevated.
The following inflammatory markers are often elevated:
*[[Complete Blood Count|CBC]]: Significant [[leukocytosis]] may be present.
*[[C-reactive protein]]
*[[Erythrocyte sedimentation rate]] ([[ESR]])


'''''Molecular markers'''''. Acute pericarditis is associated with a modest increase in serum [[creatine kinase]] MB (CK-MB)<!--
==Cardiac Biomarkers==
  --><ref name="spodick">{{cite journal | author=  Spodick DH | title= Acute pericarditis: current concepts and practice | journal= JAMA | year=2003 | pages=1150–3 | volume=289 | issue=9 | pmid=12622586 | doi= 10.1001/jama.289.9.1150}}</ref><!--
The following markers of [[myonecrosis]] may be elevated if there is involvement of the underlying [[myocardium]]:
  --><ref name="karja">{{cite journal | author=  Karjalainen J, Heikkila J | title=  "Acute pericarditis": myocardial enzyme release as evidence for myocarditis | journal= Am Heart J| year=1986| pages=546–52 | volume=111 | issue=3 | pmid=3953365 | doi=  10.1016/0002-8703(86)90062-1}}</ref> and cardiac [[troponin]] I (cTnI)<!--
*[[Creatine kinase]]: [[Acute pericarditis]] may be associated with a modest increase in serum [[creatine kinase]]-MB (CK-MB) depending upon the extent of involvement of the underlying [[myocardium]].<ref name="spodick">{{cite journal | author=  Spodick DH | title= Acute pericarditis: current concepts and practice | journal= JAMA | year=2003 | pages=1150–3 | volume=289 | issue=9 | pmid=12622586 | doi= 10.1001/jama.289.9.1150}}</ref><ref name="karja">{{cite journal | author=  Karjalainen J, Heikkila J | title=  "Acute pericarditis": myocardial enzyme release as evidence for myocarditis | journal= Am Heart J| year=1986| pages=546–52 | volume=111 | issue=3 | pmid=3953365 | doi=  10.1016/0002-8703(86)90062-1}}</ref>
  --><ref name="bonnefoy">{{cite journal | author=    Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P | title=  Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis | journal= Eur Heart J| year=2000| pages=832–6 | volume=21 | issue=10 | pmid=10781355 | doi=  10.1053/euhj.1999.1907}}</ref><!--
*[[Cardiac troponin]]-I (cTnI)<ref name="bonnefoy">{{cite journal | author=    Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P | title=  Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis | journal= Eur Heart J| year=2000| pages=832–6 | volume=21 | issue=10 | pmid=10781355 | doi=  10.1053/euhj.1999.1907}}</ref><ref name="imazio">{{cite journal | author=    Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R | title=    Cardiac troponin I in acute pericarditis | journal=  J Am Coll Cardiol| year=2003| pages=2144–8 | volume=42 | issue=12 | pmid=14680742 | doi=    10.1016/j.jacc.2003.02.001}}</ref>: The [[troponin]] can be elevated if there is an underlying [[myositis]], or a [[myopericarditis]]. In Europe, patients with [[pericarditis]] and an elevated [[troponin]] are hospitalized briefly to assure that the patient is stable.
  --><ref name="imazio">{{cite journal | author=    Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R | title=    Cardiac troponin I in acute pericarditis | journal=  J Am Coll Cardiol| year=2003| pages=2144–8 | volume=42 | issue=12 | pmid=14680742 | doi=    10.1016/j.jacc.2003.02.001}}</ref>, both of which are also markers for myocardial injury. Therefore, it is imperative to also rule out [[acute myocardial infarction]] in the face of these biomarkers. The elevation of these substances is related to inflammation of the myocardium. Also, ST elevation on [[EKG]] (see below) is more common in those patients with a cTnI > 1.5 µg/L<!--
*[[LDH]]: Serum [[LDH]] may be elevated depending upon the extent of myocardial involvement.
  --><ref name="imazio">{{cite journal | author=    Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R | title=    Cardiac troponin I in acute pericarditis | journal=  J Am Coll Cardiol| year=2003| pages=2144–8 | volume=42 | issue=12 | pmid=14680742 | doi=    10.1016/j.jacc.2003.02.001}}</ref>. [[Coronary angiography]] in those patients should indicated normal vascular perfusion. The elevation of these biomarkers are typically transient and should return to normal within a week. Persistence may indicated myopericarditis. As a summary:
*Serum [[myoglobin]]
*[[SGOT]] ([[AST]])


* [[ESR]]: mild to marked elevation
==Autoimmune Markers==
* [[CRP]]: mild to marked elevation
Following [[autoimmune]] markers may be checked in patients with recurrent or prolonged [[pericarditis]]:
* [[CK-MB]]: depends on the extent of myocardial involvement
*[[Antistreptolysin O titre]]
* [[LDH]]: depends on the extent of myocardial involvement
*[[Rheumatoid factor]] ([[RF]])
* [[troponin I]]: depends on the extent of myocardial involvement
*[[Antinuclear antibody]] ([[ANA]])
* serum myoglobin: normal (but not always, usually rises with increased ST segment deviation
*[[Anti-dsDNA antibody]]
* gallium-67 scanning: helps ID "inflammatory and leukemic infiltrations"
 
==2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)<ref name="AdlerCharron2015">{{cite journal|last1=Adler|first1=Yehuda|last2=Charron|first2=Philippe|last3=Imazio|first3=Massimo|last4=Badano|first4=Luigi|last5=Barón-Esquivias|first5=Gonzalo|last6=Bogaert|first6=Jan|last7=Brucato|first7=Antonio|last8=Gueret|first8=Pascal|last9=Klingel|first9=Karin|last10=Lionis|first10=Christos|last11=Maisch|first11=Bernhard|last12=Mayosi|first12=Bongani|last13=Pavie|first13=Alain|last14=Ristić|first14=Arsen D.|last15=Sabaté Tenas|first15=Manel|last16=Seferovic|first16=Petar|last17=Swedberg|first17=Karl|last18=Tomkowski|first18=Witold|title=2015 ESC Guidelines for the diagnosis and management of pericardial diseases|journal=European Heart Journal|volume=36|issue=42|year=2015|pages=2921–2964|issn=0195-668X|doi=10.1093/eurheartj/ehv318}}</ref>==
 
===Recommendations for the general diagnostic work-up of pericardial diseases===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.''' In all cases of suspected [[pericardial disease]] a first [[diagnostic]] evaluation is recommended with:
– [[auscultation]]
 
– [[ECG]]
 
– [[transthoracic echocardiography]]
 
– [[chest X-ray]]
 
– routine [[blood tests]], including markers of [[inflammation]] (i.e., [[CRP]] and/or [[ESR]]), white [[blood cell count]] with differential count, [[renal function]] and [[Liver function tests|liver tests]] and [[myocardial]] [[Lesions|lesion]] [[Test|tests]] ([[CK]], [[Troponin|troponins]]).
 
'''2.''' [[CT]] and/or [[CMR]] are recommended as [[second]]-level [[testing]] for [[diagnostic]] workup in pericarditis.
 
'''3.''' [[Pericardiocentesis]] or [[Drain (surgery)|surgical drainage]] are [[Indication (medicine)|indicated]] for [[cardiac tamponade]] or suspected [[bacterial]] and [[neoplastic pericarditis]].
 
'''4.''' Further testing is [[Indication (medicine)|indicated]] in high-risk [[patients]] (defined as above) according to the [[clinical]] [[conditions]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>It is recommended to search for independent predictors of an identifiable and specifically treatable cause of pericarditis (i.e. [[bacterial]], [[neoplastic]], [[systemic]] [[inflammatory diseases]]). Major factors include:
– [[fever]] >38 C
 
– [[subacute]] [[Course (medicine)|course]] ([[symptoms]] developing over several days or weeks)
 
– large [[pericardial effusion]] ([[diastolic]] echo-free space >20 mm in width)
 
– [[cardiac tamponade]]
 
– [[failure]] of [[Aspirin]] or [[NSAIDs]] ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])<ref name="ImazioDemichelis2004">{{cite journal|last1=Imazio|first1=Massimo|last2=Demichelis|first2=Brunella|last3=Parrini|first3=Iris|last4=Giuggia|first4=Marco|last5=Cecchi|first5=Enrico|last6=Gaschino|first6=Gianni|last7=Demarie|first7=Daniela|last8=Ghisio|first8=Aldo|last9=Trinchero|first9=Rita|title=Day-hospital treatment of acute pericarditis|journal=Journal of the American College of Cardiology|volume=43|issue=6|year=2004|pages=1042–1046|issn=07351097|doi=10.1016/j.jacc.2003.09.055}}</ref><ref name="ImazioCecchi2007">{{cite journal|last1=Imazio|first1=Massimo|last2=Cecchi|first2=Enrico|last3=Demichelis|first3=Brunella|last4=Ierna|first4=Salvatore|last5=Demarie|first5=Daniela|last6=Ghisio|first6=Aldo|last7=Pomari|first7=Franco|last8=Coda|first8=Luisella|last9=Belli|first9=Riccardo|last10=Trinchero|first10=Rita|title=Indicators of Poor Prognosis of Acute Pericarditis|journal=Circulation|volume=115|issue=21|year=2007|pages=2739–2744|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.662114}}</ref>''
 
''<nowiki/>''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon" |<nowiki></nowiki>  [[Percutaneous]] or [[surgical]] [[pericardial]] [[biopsy]] may be considered in selected cases of suspected [[neoplastic]] or [[tuberculous pericarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:]]<nowiki/> [[ACC AHA Guidelines Classification Scheme#Level of Evidence|C]])''
|}
 
 
===Recommendations for diagnosis of acute pericarditis===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.'''  [[ECG]] is recommended in all [[patients]] with suspected [[acute pericarditis]].
 
'''2.''' [[Transthoracic echocardiography]] is recommended in all [[patients]] with suspected [[acute pericarditis]].
 
'''3.''' [[Chest X-rays|Chest X-ray]] is recommended in all [[patients]] with suspected [[Acute pericarditis|acute pericarditis.]]
 
'''4.''' Assessment of markers of [[inflammation]] (i.e. [[CRP]]) and [[myocardial]] [[injury]] (i.e. [[CK]], [[troponin]]) is recommended in [[patients]] with suspected [[acute pericarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
===Recommendations for the diagnosis and therapy of viral pericarditis===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon" |<nowiki></nowiki> For the definited [[diagnosis]] of [[viral pericarditis]], a comprehensive workup of [[histological]], [[cytological]], [[Immunohistochemistry|immunohistological]] and [[molecular]] investigations in [[pericardial fluid]] and peri-/[[epicardial]] [[biopsies]] should be considered. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]]<nowiki/>)''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ESC guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral" |<nowiki></nowiki> '''1.''' Routine [[viral]] [[serology]] is not recommended, with the possible exception of [[Human Immunodeficiency Virus (HIV)|HIV]] and [[Hepatitis C|HCV]].
'''2.''' [[Corticosteroid]] [[therapy]] is not recommended in [[viral pericarditis]]. (''[[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
===Recommendations for the diagnosis of purulent pericarditis===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.'''  [[Urgent care|Urgent]] [[pericardiocentesis]] is recommended for the [[diagnosis]] of [[purulent pericarditis]].
 
'''2.''' It is recommended that [[pericardial fluid]] be sent for [[bacterial]], [[fungal]] and [[tuberculous]] studies and [[blood]] drawn for cultures. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 23:39, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. Homa Najafi, M.D.[2]

Overview

Non-specific markers of inflammation are generally elevated in pericarditis. These include the leukocyte count, C-reactive protein, and ESR. The cardiac troponin is elevated if there is an injury to the underlying myocardium, a condition termed as myopericarditis. Diagnostic pericardiocentesis and biopsy help in identifying an underlying infectious or malignant process.

Inflammatory Markers

The following inflammatory markers are often elevated:

Cardiac Biomarkers

The following markers of myonecrosis may be elevated if there is involvement of the underlying myocardium:

Autoimmune Markers

Following autoimmune markers may be checked in patients with recurrent or prolonged pericarditis:

2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)[5]

Recommendations for the general diagnostic work-up of pericardial diseases

Class I
1. In all cases of suspected pericardial disease a first diagnostic evaluation is recommended with:

– auscultation

– ECG

– transthoracic echocardiography

– chest X-ray

– routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function and liver tests and myocardial lesion tests (CK, troponins).

2. CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis.

3. Pericardiocentesis or surgical drainage are indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis.

4. Further testing is indicated in high-risk patients (defined as above) according to the clinical conditions. (Level of Evidence: C)

Class I
It is recommended to search for independent predictors of an identifiable and specifically treatable cause of pericarditis (i.e. bacterial, neoplastic, systemic inflammatory diseases). Major factors include:

– fever >38 C

– subacute course (symptoms developing over several days or weeks)

– large pericardial effusion (diastolic echo-free space >20 mm in width)

– cardiac tamponade

– failure of Aspirin or NSAIDs (Level of Evidence: B)[6][7]

Class IIb
Percutaneous or surgical pericardial biopsy may be considered in selected cases of suspected neoplastic or tuberculous pericarditis. (Level of Evidence: C)


Recommendations for diagnosis of acute pericarditis

Class I
1. ECG is recommended in all patients with suspected acute pericarditis.

2. Transthoracic echocardiography is recommended in all patients with suspected acute pericarditis.

3. Chest X-ray is recommended in all patients with suspected acute pericarditis.

4. Assessment of markers of inflammation (i.e. CRP) and myocardial injury (i.e. CK, troponin) is recommended in patients with suspected acute pericarditis. (Level of Evidence: C)

Recommendations for the diagnosis and therapy of viral pericarditis

Class IIa
For the definited diagnosis of viral pericarditis, a comprehensive workup of histological, cytological, immunohistological and molecular investigations in pericardial fluid and peri-/epicardial biopsies should be considered. (Level of Evidence: C)
Class III
1. Routine viral serology is not recommended, with the possible exception of HIV and HCV.

2. Corticosteroid therapy is not recommended in viral pericarditis. (Level of Evidence: C)

Recommendations for the diagnosis of purulent pericarditis

Class I
1. Urgent pericardiocentesis is recommended for the diagnosis of purulent pericarditis.

2. It is recommended that pericardial fluid be sent for bacterial, fungal and tuberculous studies and blood drawn for cultures. (Level of Evidence: C)

References

  1. ↑ Spodick DH (2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. doi:10.1001/jama.289.9.1150. PMID 12622586.
  2. ↑ Karjalainen J, Heikkila J (1986). ""Acute pericarditis": myocardial enzyme release as evidence for myocarditis". Am Heart J. 111 (3): 546–52. doi:10.1016/0002-8703(86)90062-1. PMID 3953365.
  3. ↑ Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P (2000). "Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis". Eur Heart J. 21 (10): 832–6. doi:10.1053/euhj.1999.1907. PMID 10781355.
  4. ↑ Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R (2003). "Cardiac troponin I in acute pericarditis". J Am Coll Cardiol. 42 (12): 2144–8. doi:10.1016/j.jacc.2003.02.001. PMID 14680742.
  5. ↑ Adler, Yehuda; Charron, Philippe; Imazio, Massimo; Badano, Luigi; Barón-Esquivias, Gonzalo; Bogaert, Jan; Brucato, Antonio; Gueret, Pascal; Klingel, Karin; Lionis, Christos; Maisch, Bernhard; Mayosi, Bongani; Pavie, Alain; Ristić, Arsen D.; Sabaté Tenas, Manel; Seferovic, Petar; Swedberg, Karl; Tomkowski, Witold (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.
  6. ↑ Imazio, Massimo; Demichelis, Brunella; Parrini, Iris; Giuggia, Marco; Cecchi, Enrico; Gaschino, Gianni; Demarie, Daniela; Ghisio, Aldo; Trinchero, Rita (2004). "Day-hospital treatment of acute pericarditis". Journal of the American College of Cardiology. 43 (6): 1042–1046. doi:10.1016/j.jacc.2003.09.055. ISSN 0735-1097.
  7. ↑ Imazio, Massimo; Cecchi, Enrico; Demichelis, Brunella; Ierna, Salvatore; Demarie, Daniela; Ghisio, Aldo; Pomari, Franco; Coda, Luisella; Belli, Riccardo; Trinchero, Rita (2007). "Indicators of Poor Prognosis of Acute Pericarditis". Circulation. 115 (21): 2739–2744. doi:10.1161/CIRCULATIONAHA.106.662114. ISSN 0009-7322.

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