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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| Image = Mesothelial cyst of the pericardium.jpg|
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| Caption = Mesothelial cyst of the pericardium. Note the rounded mass in the right costophrenic angle (arrow). <br> <small> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small>|
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| DiseasesDB = 9820 |
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| ICD10 = {{ICD10|I|01|0|i|00}}, {{ICD10|I|09|2|i|05}}, {{ICD10|I|30||i|30}}-{{ICD10|I|32||i|30}} |
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| ICD9 = {{ICD9|420.90}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000182 |
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| eMedicineSubj = med |
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| eMedicineTopic = 1781 |
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| eMedicine_mult = {{eMedicine2|emerg|412}} |
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| MeshName = Pericarditis |
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| MeshNumber = C14.280.720 |
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| }}
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| {{SI}}
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
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| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}
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| __NOTOC__ | | __NOTOC__ |
| '''Associate Editor-In-Chief:''' {{CZ}} | | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Pericarditis resident survival guide]]|| <br> || <br> |
| | | [[Pericarditis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| | {{Patient}} |
| | {{Pericarditis}} |
| | {{CMG}}; {{AE}}{{Homa}}[[Varun Kumar, M.B.B.S.]]; {{CZ}} |
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| {{Editor Join}} | | {{SK}}[[acute pericarditis]], [[chronic pericarditis]], [[idiopathic pericarditis]], [[recurrent pericarditis]], [[chronic effusive pericarditis]], [[chronic constrictive pericarditis]], [[inflammation of the pericardium]], [[pericardial inflammation]], [[inflammation of the pericardial sac]], [[serous pericarditis]], [[purulent pericarditis]], [[hemorrhagic pericarditis]], [[fibrinous pericarditis]], [[caseous pericarditis]], [[bacterial pericarditis]], [[viral pericarditis]], [[fungal pericarditis]], [[parasitic pericarditis]], [[autoimmune pericarditis]], [[neoplastic pericarditis]], [[metabolic pericarditis]], [[traumatic pericarditis]], [[iatrogenic pericarditis]], [[drug-related pericarditis]], [[postoperative pericarditis]], [[post-operative pericarditis]], [[post-surgery pericarditis]], [[postsurgery pericarditis]], [[acute recurrent pericarditis]], [[radiation induced pericarditis]], [[radiation-induced pericarditis]], [[uremic pericarditis]], [[radiation induced constrictive pericarditis]], [[children pericarditis]], [[pericarditis in children]] |
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| ==Overview== | | == [[Pericarditis overview|Overview]] == |
| [[Diseases of the pericardium overview | Diseases of the pericardium overview]] | |
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| ==Pathophysiology & Etiology== | | == [[Pericardium|Pericardial Anatomy]] == |
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| [[Pericarditis overview of pathophysiology & etiology | Overview]] | [[The Most Frequent Causes of Pericarditis | The Most Frequent Causes of Pericarditis]] | [[Pericarditis causes | Pericarditis causes]] | | == [[Pericarditis classification|Classification]] == |
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| | == [[Pericarditis pathophysiology|Pathophysiology]] == |
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| ===Complete List of Causes of pericarditis=== | | == [[Pericarditis causes|Causes]] == |
| | [[HIV]] | [[Dressler's syndrome|Post-MI]] | [[Postpericardiotomy syndrome|Post-pericardiotomy]] | [[Radiation induced pericarditis|Radiation]] | [[Tuberculous pericarditis|Tuberculosis]] | [[Uremic pericarditis|Uremia]] | [[Pericarditis in malignancy|Malignancy]] |
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| # '''Infectious:'''
| | == [[Pericarditis differential diagnosis|Differentiating Pericarditis from other Diseases]] == |
| #* Viral: [[Coxsackie B Virus]], [[Echovirus]], [[Adenovirus]] (less commonly: [[Mumps]], [[Influenza]], [[varicella]], [[Hepatitis B]] and [[CMV]]-especially in [[HIV]] patients.) Usually associated with a viral prodrome and acute pericarditis.
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| #* [[Tuberculosis]]: usually bloody, protein greater than 2.5. Initially mostly [[polymorphonuclear cells]], later [[lymphocytes]], [[monocytes]] and [[plasma cells]]. Usually develops very slowly with significant fibrous reaction. Initially effusive then becomes constrictive.
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| #* Purulent: [[Pneumococcus]], [[Streptococcus]] and [[Staphylococcus]] most common. Also Proteus, [[E.coli]], Psuedomonas, [[Klebsiella]], [[Brucellosis]], [[Salmonella]], [[Neisseria]], [[Haemophilus influenza]], [[Tularemia]], [[Legionella]], preodominantly by hematogenous spread and approximately 20% by contiguous spread. Usually these patients are quite ill.
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| #* Fungal: [[Histoplasmosis]], [[Coccidiomycosis]], [[Aspergillus]], [[Blastomycosis]], [[Candida]].
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| #* Other: [[Toxoplasmosis]], [[Amebiasis]], [[Mycoplasma]], [[Nocardia]], [[Actinomycosis]], [[Echinococcus]], [[Lyme disease]] (usually myopericarditis associated with conduction abnormalities).
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| # '''Neoplastic:'''
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| #* Predominantly lung, breast, [[leukemia]], [[lymphomas]] ([[Hodgkins]] and non-Hodgkins). Less commonly GI malignancies, [[ovarian cancer]], [[sarcoma]]s and [[melanoma]]s, metastic, hematogenous, [[carcinoma]], [[carcinoid]], [[Sipple syndrome]], [[mesothelioma]], [[fibroma]], [[lipoma]] . Also [[Kaposis sarcoma]] in [[HIV]] positive patients.
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| # '''Uremic:'''
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| #* [[Uremic]] pericarditis is seen in up to 20% of uremic patients requiring chronic hemodialysis. The mechanism is unknown. Most commonly there is a small effusion associated with pain and a [[pericardial friction rub]], but there can be a large effusion and present with [[tamponade]].
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| # '''Autoimmune:'''
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| #* [[Systemic Lupus Erythematosus]] or [[SLE]]: Pericarditis usually occurs in the setting of disease flares (systemic symptoms, high erythrocyte sedimentation rate ([[ESR]]) , +ANA, +dsDNA, [[pleural effusion]]s). Occurs in 20-40% of patients with [[SLE]] during the course of the disease. Usually the fluid is serous or grossly bloody. Analysis of the fluid usually reveals a high protein and low glucose content. Typically [[WBC]] count is less than 10K, and is made up of primarily [[polymorphonuclear cell]]s ([[PMN]]s).
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| #* [[Rheumatoid arthritis]] or [[RA]]: Pericarditis can occur without active joint involvement. Also serous or bloody. Usually the protein is > 5 mg/dl, and the glucose is low (<45). The [[WBC]] is high at 20-90K. Complement is usually low, and the latex fixation test is usually positive.
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| #* Other: Acute [[rheumatic fever]], [[scleroderma]], mixed [[connective tissue disease]], [[Wegener's]], [[PAN]].
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| # '''[[Trauma]]tic:'''
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| #* After chest trauma, throacic surgery, PCM insertion, [[Valvuloplasty]]. Also from [[esophageal rupture]], pancreatic-pericardial fistula (check amylase), penetrating chest injury, esophogeal perforation, gastric perforation, during catheterization (pacemaker insertion, cathether ablation for [[arrhythmias]], diagnostic, PCI with coronary dissection).
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| # '''Drugs:'''
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| #* Usually associated with small effusions. Common culprits include [[hydralazine]], [[procainamide]], DOH, [[isoniazid]], [[phenylbutazone]], [[dantrolene]], [[doxorubicin]], methylsergide, [[penicillin]].
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| # '''Hypothyroidism:'''
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| #* Usually in conjunction with clinically severe [[hypothyroidism]]. Most early case reports associated with [[myxedema]] and patients also had [[ascites]], [[pleural effusion]]s and uveal edema. Often resolves with thyroid replacement therapy.
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| # '''Other:'''
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| #* Post-MI ([[Dresslers]]), post-pericardiotomy, [[radiation]], [[dissecting aortic aneurysm]], chylopericardium (from thoracic duct obstruction secondary to tumor, surgical procedure, [[trauma]], [[TB]], congenital). Also, [[sarcoidosis]], [[amyloidosis]], [[IBD]], [[Whipple's]], [[temporal arteritis]] and [[Behcet syndrome]]).
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| ==Differential Diagnosis for Diseases of the Pericardium == | | == [[Pericarditis epidemiology and demographics|Epidemiology and Demographics]] == |
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| Many other conditions produce signs and symptoms similar to those produced by pericarditis. Keep in mind that pericarditis might also be one of the following: "part of a generalized disease", "apparently isolated", or "part of a disease that affects a nearby organ", and "sometimes is the presenting syndrome of multiple diseases."
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| '''Key Signs & Symptoms to Differentiate Pericarditis:'''
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| # Pain on the trapezius ridge(s), is a pathognomonic of pericarditis. Often pain can radiate mimicking pain that is commonly felt during angina.
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| # Central pleuritic chest pain (can also be indicative of pleurisy; however, may be both)
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| # Pain that lasts longer, is sharper and unresponsive to vasodilator therapy (similar "to that of cardiac ischemia")
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| # Most acute pericarditis ECGs are similar to ECGs of ischemic heart disease rather than infarction
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| # [[Pulmonary embolism]] can present similarly to pericarditis, but can be differentiated from pericarditis in the presence of one of the following findings: a nonspecifically altered ECG, a plerual rub, and non-precordial (someitmes precordial pain is present regardless).
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| === Acute Pericarditis ===
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| *[[Actinomycosis]]
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| *[[Acute idiopathic pericarditis]]
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| *[[Acute rheumatic fever]]
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| *[[Adenovirus]]
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| *[[Addison's crisis]]
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| *[[Amyloidosis]]
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| *[[Amebiasis]]
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| *[[Ankylosing Spondylitis]]
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| *[[Aortic dissection]]
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| *[[Behcet's Disease]]
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| *[[Borrelia]]
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| *[[Breast cancer]]
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| *[[Chylopericardium]]
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| *[[Coxsackie A]]
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| *[[Coxsackie B]]
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| *[[Cytomegalovirus]]
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| *[[Dermatomyositis]]
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| *[[Dermatosclerosis]]
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| *[[Dressler's Syndrome]]
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| *[[EBV]]
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| *[[ECHO virus]]
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| *[[Echinococcosis]]
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| *[[Familial Mediterranian Fever]]
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| *[[Francisella]]
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| *[[HIV]]
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| *[[Infectious mononucleosis]]
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| *[[Inflammatory Bowel Disease]]
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| *[[Influenza virus]]
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| *[[Legionella]]
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| *[[Leukemia]]
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| *[[Lung cancer]]
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| *[[Lymphoma]]
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| *[[Meningococci]]
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| *[[Mixed Connective Tissue Disease]]
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| *[[Mumps virus]]
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| *[[Mycoplasma infection]]
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| *[[Neisseria gonorrhoeae]]
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| *[[Perforated esophagus]]
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| *[[Pneumococci]]
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| *[[Polyarteritis Nodosa]]
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| *[[Polymyositis]]
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| *[[Postpericardiotomy syndrome]]
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| *[[Reiter's Syndrome]]
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| *[[Radiation therapy]]
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| *[[Renal Failure]]
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| *[[Rheumatoid Arthritis]]
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| *[[Rickettsia]]
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| *[[Sarcoidosis]]
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| *[[Scleroderma]]
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| *[[Serum sickness]]
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| *[[Staphylococci]]
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| *[[Streptococci]]
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| *[[Systemic Lupus Erythematosus]]
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| *[[Thorax trauma]]
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| *[[Treponema pallidum]]
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| *[[Toxoplasmosis]]
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| *[[Tuberculosis]]
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| *[[Uremia]]
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| *[[Varicella virus]]
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| *[[Wegener's granulomatosis]]
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| *[[Whipple's Disease]]
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| === Chronic Pericarditis ===
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| *[[Amebiasis]]
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| *[[Bacterial infections]]
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| *[[Cholesterol pericarditis]]
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| *[[Chylopericardium]]
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| *[[Coccidioidomycosis]]
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| *[[Collagen Vascular Disease]]
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| *[[Coxsackie B]]
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| *[[Echinococcosis]]
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| *[[Histoplasmosis]]
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| *[[Neoplastic pericarditis]]
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| *[[Tuberculosis]]
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| *[[Uremic pericarditis]]
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| == Clinical presentation ==
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| [[Chest pain]], radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry [[cough]], [[fever]], fatigue and [[anxiety]]. Pericarditis can be misdiagnosed as [[myocardial infarction]], and vice versa.
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| The classic [[medical sign|sign]] of pericarditis is a [[pericardial rub|friction rub]]. Other signs include ST-elevation and PR-depression on [[Electrocardiogram|EKG]] (all leads); [[cardiac tamponade]] ([[pulsus paradoxus]] with [[hypotension]]), and [[congestive heart failure]] (elevated [[jugular venous pressure]] with [[peripheral edema]]).
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| ==Natural History==
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| Most cases of acute idiopathic pericarditis resolve without complications or recurrence.
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| Complications may include:
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| * [[Pericardial effusion]]
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| * [[Constrictive pericarditis]]
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| * [[Cardiac tamponade]] [http://www.mayoclinic.com/invoke.cfm?objectid=CE3BC2CF-B4C1-4401-8F0F9E0B7C284538&dsection=6]
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| ==Types & Forms of Pericarditis==
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| * A. Congenital Diseases of the Pericardium
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| :* [[Congenital absence of the pericardium]]
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| :* [[Pericardial cysts]]
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| * B. Acquired Diseases of the Pericardium
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| :* [[Pneumopericardium]]
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| == Diagnosis ==
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| == History and Symptoms ==
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| A diagnosis of pericarditis can be made depending on its etiology and speed of onset. For example, both uremic and tuberculosis induced pericarditis develop more slowly and can be undetectable until presenting "as a fever of unknown origin." On the other hand, both bacterial and viral pericarditis develop rapidly and can present as increasing "pain over several hours."
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| ===Symptoms:===
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| # [[Chest Pain]]: however, pain is often absent (depending on the type of pericarditis e.g. rheumatoid pericarditis). It is the most common symptom.
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| #* Some causes of pain include: inflammation of the pericardium, phrenic nerves, and nearby pleura.
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| #* Quality of pain: sharp, "sticking", dull, aching, or pressure-like. It can be rated anywhere from 1-10. In the beginning stages, the pain usually starts out as sharp. "Inspiration and cough" can increase the pain so patients usually "sit upright for relief."
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| # Nonproductive [[cough]] that elicites pleuritic pain
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| # Productive [[cough]], which usually occurs in the presence of other illness(es)
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| # [[Hiccup]] (rarely)
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| # [[Odynophagia]] with or without [[Dysphagia]]
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| # [[Faintness]] and [[Dizziness]] (uncommon unless [[cardiac tamponade]] is present]]
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| # [[Chest wall]] [[palpitations]]: causing local tenderness and may be indicative of [[costochondritis]], [[Tietze syndrome]], or [[rib fractures]] (in cases of traumatic pericarditis)
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| == Physical Examination ==
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| === Appearance of the Patient with Pericarditis ===
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| # [[Fever]] less than 39° C or 102.2° F
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| #* Patients who are elderly may not exhibit fever; however, they may be [[hypothermic]] especially those with [[renal failure]].
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| # [[Chills]] (suppurative pericarditis and idiopathic (viral) pericarditis)
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| # [[Weakness]]
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| # [[Depression]]
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| # [[Anxiety]]
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| # [[Pallor]] (may also indicate [[tuberculosis]], [[uremia]], [[neoplasia]], and rheumatic carditis)
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| === Heart ===
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| '''Ausculatory Phenomena:'''
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| # Pericardial Rub(s): Usually heard with acute pericarditis, sometimes with subacute and chronic. This is the major indicator of pericarditis.
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| #* endopericardial rub: inflamed, scarred or tumor-invaded serosal surfaces
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| #* exopericardial rub: after sclerotherapy of effusions, between parietal pericardium and pleura or chest wall (occasionally)
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| #* endo-exopericardial rub: both of the above
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| #* pleuropericardial rub: [[pleuritis]] as a result of pleural or both pleural and pericardial both
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| # Abnormal Heart Sounds:
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| #* Sounds are dampened as a result of fluid insullation
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| #* Hemodynamic changes diminish S<sub>1</sub> and S<sub>2</sub>
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| # Clicks: Ventricular volume shrinks disproportionately and psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures result in clicks.
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| # Murmurs: are epiphenomena and may be present if there is coinciding heart disease, narrowing of a valve, aorta, pulmonary artery or another area of the heart.
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| === Lungs ===
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| [[Rales]] are frequent examination findings, occasionally [[pleural fluid]] may present.
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| === Extremities ===
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| #May be poorly perfused in the setting of tamponade
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| #Edema may be present in the setting of pericardial constriction
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| == Laboratory Findings ==
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| === Electrolyte and Biomarker Studies ===
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| '''''Inflammatory markers'''''. A [[Complete Blood Count|CBC]] may show an elevated white count and a serum [[C-reactive protein]] may be elevated.
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| '''''Molecular markers'''''. Acute pericarditis is associated with a modest increase in serum [[creatine kinase]] MB (CK-MB)<!--
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| --><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><!--
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| --><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)<!--
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| --><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><!--
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| --><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<!--
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| --><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:
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| * [[ESR]]: mild to marked elevation
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| * [[CRP]]: mild to marked elevation
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| * [[CK-MB]]: depends on the extent of myocardial involvement
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| * [[LDH]]: depends on the extent of myocardial involvement
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| * [[troponin I]]: depends on the extent of myocardial involvement
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| * serum myoglobin: normal (but not always, usually rises with increased ST segment deviation
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| * gallium-67 scanning: helps ID "inflammatory and leukemic infiltrations"
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| === Electrocardiogram ===
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| '''[[Electrocardiography|EKG Abnormalities]]:''' Increase in scar tissue, fluid and fibrin can reduce voltage, quasi-specific ST-T waves can present. The [[EKG]] abnormalities vary depending on the stage/severity of the pericarditis. Below are the stages/types of pericarditis:<!--
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| --><ref name="troughton">{{cite journal | author= Troughton RW, Asher CR, Klein AL | title= Pericarditis | journal= Lancet| year=2004| pages=717–27 | volume=363 | issue=9410 | pmid=15001332 | doi= 10.1016/S0140-6736(04)15648-1}}</ref><!--
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| --><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>
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| [[Image:Stadia pericarditis.png|thumb|left|600px|Several stages of pericarditis. Stage I: ST elevation in all leads; PTa depression (depression between the end of the P wave and the beginning of the QRS complex). Stage II: Pseudonormalization (transition). Stage III: inverted T waves. Stage IV: normalization. (Courtesy of ECGpedia)]]
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| <br clear="left"/>
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| #''Acute Pericarditis'' (see also [[Electrocardiography#The PR Interval]] and [[Electrocardiography#The EKG of Cardiac Transplantation]]): this variation of the disease in conjunction with myocarditis can lead to ST-T anomalies that are characteristic of the acute stages of pericarditis.
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| #*''Stage 1'': Stage 1 of acute pericarditis, in and of itself, presents as "early repolarization" and acute infarction. It shows signs of anterior and inferior ST elevation on the [[EKG]]. There are usually no deviations in the QRS complex. This stage is largely characteristic of acute pericarditis when almost all of the leads are effected. Leads I, II, avL, avF, and V<sub>3</sub>-V<sub>6</sub>.
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| #*''Stage 2'': During the early phase of this stage, ST segments should become baseline again; whereas, PR segments may have deviated. During the latter phase of stage 2, the ST segments that were previously elvated usually flatten and invert.
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| #*''Stage 3'': Virtually all of the leads in stage 3 exhibit T wave inversion. Acute pericarditis cannot be diagnosed on an [[ECG]] of a stage 3 patient because its presentation is the same as myocardial injury and frank myocarditis.
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| #*''Stage 4'': This stage presents itself on the [[EKG]] as a return to a prepericarditis state. Stage 4 does not always occur and in its absence, there can be residual T wave inversions that may be permanent, generalized or focal.
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| #''Rate and Rhythm'': Rapid heart rates are typical in patients with pericarditis, but in patients with uremic pericarditis slower rates are observed. Heart rhythms appear normal unless there is another complication such as cardiac disease, the presence of myocardial/pericardial tumor, or a metabolic disorder.
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| #''[[Pericardial Effusion]]'' (see also [[Electrocardiography#Amplitude]]): These can present differently on the [[EKG]] depending on whether they are chronic vs large effusions. The former typically leads to low amplitude [[EKG]]s; whereas, the latter can show no voltage or various [[Electrocardiography|ECG abnormalities]]. ST-T wave abnormalities can be caused by superficial myocarditis or because of the accumulated fluid, they may be caused by the compression of the myocardium or [[ischemia]]. The primary cause of ST segment variation during pericardial effusions is usually the rapid accumulation of fluid. Large effusions can lead to the reduction of P wave voltage. [[Pleural effusions]] can cause a decrease in voltage, which occurs mainly on the left. Also, [[cirrhosis]] and [[congestive heart failure]] ([[CHF]]), which similarily involve the accumulation of fluid in the body, can decrease voltage in the absence of any pericardial disease.
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| #''[[Cardiac tamponade]]'' (see also [[Cardiac tamponade#Electrocardiogram]]): Generally has little [[EKG]] effect; however, in the acute form, tamponade may present on the [[EKG]] as any one of the stages of acute pericarditis.
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| #''Electrical Alternation'': This occurs more often in cases of tamponade than in those of pericarditis (2:1). There is alternation of the QRS complex on the spatial axis. Alternation of the T wave, P wave, and PR segement are difficult to see and are uncommon. The removal of even a small amount of fluid can end alternation.
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| #''Early Repolarization'': This finding can be misleading and may look like pericarditis, when in fact it is not. A strong indication of pericarditis is "if the J point is more than 25% the height of the T wave apex."
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| #''Constrictive Pericarditis'': Cases of constrictive pericarditis have nonspecific [[EKG]] abnormalities. Common abnormalities include: a slightly "low voltage QRS" segment combined with "flattened to inverted T waves", during stage 3 of acute/subacute constriction the T wave inversions remain or worsen and "P waves can be wide and bifid." It is not uncommon for patients to have normal [[EKG]]s. Many patients may only exhibit "nonspecific T wave abnormality." Other influencial factors that may effect the [[EKG]] in constrictive pericarditis are: [[fluid retention]], [[ascites]], and [[pleural effusions]]. The two most common [[arrhythmias]] that occur are [[atrial fibrillation]] and [[atrial flutter]].
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| #*''QRS Abnormality'': characteristic RV hypertrophy QRS abnormalities may develop as a result of disproportionate constriction or postpericardiectomy scarring. Also, "focal atrophy, scarring or inflamation" may cause "abnormal Q waves."
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| #**''Chronic Constrictive Pericarditis'': low volatage and myocardial atrophy, "frontal QRS axis" is usually vertical (becomes more vertical with increasing chronicity),
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| #**''Acute/Subacute Pericarditis'': QRS axis appears as normal
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| [[Image:Acute-pericarditis.jpg|left|350px|thumb|Acute Pericarditis]]
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| [[Image:Ptadepressieecg.png|left|350px|thumb|Acute Pericarditis]]
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| [[Image:12leadpericarditis.png|left|350px|thumb|Acute Pericarditis]]
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| [[Image:Peri022.jpg|left|350px|thumb|Acute Pericarditis]]
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| [[Image:Ptadepressie.png|left|350px|thumb|An example of clear PTa depression]]
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| [[Image:Alternans.jpg|left|350px|thumb|Pericardial Effusion]]
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| ====Summary of EKG findings====
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| Typical lead involvement: I, II, aVL, aVF, and V3-V6.
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| The ST segment is always depressed in aVR, frequently in V1, and occasionally in V2. Occasionally, stage IV does not occur and there are permanent T wave inversions and flattenings.
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| If EKG is first recorded in stage III, pericarditis cannot be differentiated by EKG from diffuse myocardial injury, "biventricular strain," or myocarditis.
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| EKG in early repolarization is very similar to stage I. Unlike stage I, this EKG does not acutely evolve and J point elevations are usually accompanied by a slur, oscillation, or notch at the end of the QRS just before and including the J point (best seen with tall R and T waves – large in early repolarisation pattern).
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| Pericarditis is likely if in lead V6 the J point is >25% of the height of the T wave apex (using the PR segment as a baseline).
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| === Chest X Ray ===
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| The heart will be enlarged on CXR in the setting of [[tamponade]] with a significant pericardial effusion.
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| [[Image:Mesothelial cyst of the pericardium.jpg|left|thumb|350px|Mesothelial cyst of the pericardium. Note the rounded mass in the right costophrenic angle (arrow).]]
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| === Cardiac MRI <small><ref>Higgins CB, De Roos A (2003) Cardiovascular MRI and MRA. Lippincott Williams & Wilkins, Philadelphia</ref></small> ===
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| CMR provides good resolution for identifying many types of pericardial pathology. On T1-weighted spin echo imaging, the pericardium appears as a thin, low-signal band bordered by bright, high-signal bands corresponding to epicardial and pericardial fat. The pericardium on CMR appears black because of its low water content. With gadolinium, however, it may enhance in acute inflammation. Normal thickness of the pericardium on CMR is 2-4mm, although the thickness has been shown to be slightly greater than expected from pathological studies due to chemical shift caused by the fat overlying the pericardium.
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| ====Cardiac MRI in Constrictive pericarditis====
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| Because pericardial thickness is easily measured on CMR, it is considered the definitive approach for diagnosis of constrictive pericarditis; coronal and axial spin-echo CMR have been reported to have a sensitivity of 88%, specificity of 100%, and diagnostic accuracy of 93% in making this diagnosis. In addition, depending on the severity of the constrictive pericarditis, dilatation of the IVC, hepatic veins, and right atrium as well as a normal or compressed/elongated right ventricle can be seen. Differentiating between causes of pericardial thickening can be difficult, however; inflammatory etiologies usually lead to greater thickening than [[Category:]]fibrotic ones. Also, in chronic constriction the thickened pericardium displays a lower intensity than in acute pericarditis.
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| ====Cardiac MRI in pericardial effusions====
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| It is important to distinguish the thickness of the pericardium from any pericardial effusion, which commonly appears black on spin echo images but bright on gradient echo cines. Moderate-sized effusions are often associated with a pericardial space anterior to the right ventricle of size greater than 5mm. Cine images can detect cardiac tamponade by revealing diastolic collapse of right sided and sometimes left-sided cardiac chambers. Regarding the composition of pericardial effusions, transudates have low signal on T1-weighted images but high signal on T2-weighted and gradient echo images. Exudates display an intermediate signal on both types of sequences. Hemorrhagic effusions may show a wide range of signal intensity on spin-echo sequences that depends on the age of the effusion.
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| ====Cardiac MRI in other pericardial pathologies====
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| Other types of pericardial pathology detectable by CMR include pericardial cysts; metastasis and primary tumors of the pericardium; and intracardiac tumors such as myxomas, lipomas, and teratomas. The signal intensity of fluid within pericardial cysts increases progressively with echo time, leading to accurate detection. Pericardial calcification, on the other hand, is not well-detected by CMR. Calcium appears black on CMR and therefore may resemble a localized area of pericardial thickening; cardiac CT is preferred for visualizing pericardial calcification.
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| ===Computed Tomography (CT) <small><ref>Chotas HG, Dobbins JT, Ravin CE (1999) Principles of digital radiography with large-area, electronically readable detectors: a review of the basics. Radiology 210:595-599</ref> <ref>Ohnesorge BM, Becker CR, Flohr TG, Reiser MF (2001) Multislice CT in cardiac imaging. Springer-Verlag</ref> </small>===
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| '''Pericardial Effusion'''
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| Cross-sectional imaging by CT or MRI is very sensitive in the detection of generalized or loculated pericardial effusions. Some fluid in the pericardial sac contributes to the apparent thickness and should be considered normal. Commonly, free-flowing fluid accumulates first at the posterolateral aspect of the left ventricle, when the patient is imaged in the supine position.
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| Estimation of the amount of fluid is possible to a limited extent based on the overall thickness of the crescent of fluid. Compared to cardiac ultrasound, CT and MRI may be particularly helpful in detecting loculated effusions, owing to the wide field of view provided by these techniques. Hemorrhagic effusions can be differentiated from a transudate or an exudate based on signal characteristics (high signal on T1-weighted images) or density (high-density clot on CT). Pulsation artefacts may cause local areas of low signal in a hemorrhagic effusion. Effusions are often incidentally noted on CT scans obtained for other indications.
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| Pericardial thickening (thickness >4 mm) is difficult to differentiate from a small generalized effusion. Both entities will reveal a low signal/density line that is thicker than the normal pericardial thickness. In acute pericarditis, the pericardial lining can show intermediate signal intensity and may enhance after gadolinium administration.
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| [[Image:Pericard-effusion-01.jpg|left|thumb|350px|Chest x-ray: Pericardial effusion]]
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| [[Image:Pericard-effusion-02.jpg|left|thumb|350px|Chest x-ray: Pericardial effusion. The second day of admission]]
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| [[Image:Pericard-effusion-03.jpg|left|thumb|350px|Cardiac MSCT: Pericardial effusion]]
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| '''Constrictive Pericarditis'''
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| Pericardial thickening may result in constrictive pericarditis. In this entity, pericardial thickening will hamper cardiac function, with hemodynamic consequences. Many disease conditions can lead to constrictive pericarditis (infection, tumor, radiation, heart surgery, etc.).
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| The diagnostic features include thickened pericardium in conjunction with signs of impaired right ventricular function: dilatation of caval veins and hepatic veins, enlargement of the right atrium, and the right ventricle itself may be normal or even reduced (tubular, sigmoid) in size due to compression. Localized pericardial thickening may also cause functional impairment (localized constrictive pericarditis). Sometimes constriction may occur despite a normal appearance of the pericardium.
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| Pericardial calcifications are easily visualized by CT but may be difficult or impossible to appreciate on MRI.
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| '''Pericardial Tumor'''
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| A pericardial cyst is most commonly located at the right cardiophrenic angle. On T1, it appears either as a low signal or an intermediate signal due to high protein content, or with a characteristic light-bulb appearance on T2.
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| Unusual tumors may arise from the pericardium (mesothelioma, angiosarcoma, etc.). Malignant primary tumors have many overlapping imaging features and generally cannot be differentiated. The role of cross-sectional imaging is to establish a diagnosis and to define the extent of the lesion (invasion of cardiac structures, veins, pericardium, etc.). Sometimes lesions may have helpful signal characteristics to suggest a specific diagnosis, e.g., high-signal fat on T1 or low-density fat on CT in lipoma / liposarcoma.
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| Secondary tumors are much more common than primary tumors. Lung cancer may invade the mediastinal and cardiac structures directly or indirectly.
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| The most common secondary tumors affecting the heart are lung cancer, breast cancer, and lymphoma. Metastatic pericardial disease commonly presents as hemorrhagic effusion. Tumor nodules may enhance after intravenous gadolinium administration.
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| '''Pericardial Metastases'''
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| [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| [[Image:Pericardial metastasis 1.jpg|left|thumb|350px|Pericardial Metastases]]
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| [[Image:Pericardial metastasis 2.jpg|left|thumb|350px|Pericardial Metastases]]
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| [[Image:Pericardial metastasis 3.jpg|left|thumb|350px|Pericardial Metastases]]
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| [[Image:Pericardial metastasis 4.jpg|left|thumb|350px|Pericardial Metastases]]
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| [[Image:Pericardial metastasis 5.jpg|left|thumb|350px|Pericardial Metastases]]
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| [[Image:Pericardial metastasis 6.jpg|left|thumb|350px|Pericardial Metastases]]
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| === [[Echo in pericardial diseases: effusion, cardiac tamponade, constriction|Echocardiographic Findings]]===
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| ===Radioscopic Findings===
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| * Calcified pericardium in constructive pericarditis
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| <youtube v=blSXL5z02fY/>
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| <youtube v=LXWitpJQEGQ/>
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| ===Pathological Findings===
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| ====Gross Images====
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0001.jpg|Fibrinous pericarditis: Gross, natural color, an excellent example of bread and butter appearance. Uremia, chronic glomerulonephritis and sepsis.
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| Image:Pericarditis 0002.jpg|Fibrinous pericarditis: Gross, a good example (bread and butter appearance).
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| Image:Pericarditis 0003.jpg|Fibrinous pericarditis: Gross, an excellent example.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0004.jpg|Fibrinous pericarditis: Gross, an excellent example, close-up view of fibrin.
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| Image:Pericarditis 0005.jpg|Fibrinous pericarditis: Gross, an excellent example, close-up view.
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| Image:Pericarditis 0006.jpg|Fibrinous pericarditis: Gross, an excellent example.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0007.jpg|Fibrinous pericarditis: Gross, external view of localized pericarditis over an acute infarction
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| Image:Pericarditis 0008.jpg|Fibrinous pericarditis: Gross, intact heart, good example
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| Image:Pericarditis 0009.jpg|Fibrinous pericarditis: Gross, good example, mild, with small amount of fibrin
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0010.jpg|Fibrinous pericarditis: Gross, close-up, an excellent example of color and detail
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| Image:Pericarditis 0011.jpg|Fibrinous pericarditis: Gross, a good example
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| Image:Pericarditis 0012.jpg|Fibrinous pericarditis: Gross, a good example, very mild case
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0013.jpg|Fibrinous pericarditis: Gross, an excellent example.
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| Image:Pericarditis 0014.jpg|Fibrinous pericarditis: Gross, a close-up view, an excellent illustration of fibrinous exudate.
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| Image:Pericarditis 0015.jpg|Pericarditis in [[uremia]]
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0016.jpg|Fibrinous pericarditis: Gross, fixed tissue (note to color changes), a close-up view of fibrin on epicardial surface of heart. A typical example.
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| Image:Pericarditis 0017.jpg|Fibrinous pericarditis: Gross, natural color, large right atrial thrombus and fibrinous pericarditis. Normal [[tricuspid valve]] with some aging changes (good example)
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| Image:Pericarditis 0018.jpg|Fibrinous pericarditis: Gross, natural color
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0019.jpg|Fibrinous pericarditis: Gross, natural color, an excellent example
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| Image:Pericarditis 0020.jpg|Fibrinous pericarditis: Gross, natural color, very close-up photo showing fibrinous exudate simulating frost (an excellent example)
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| Image:Pericarditis 0021.jpg|Rheumatoid fibrinous pericarditis: Gross, natural color, a typical lesion in 22 years old white female due to juvenile rheumatoid arthritis.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0022.jpg|Fibrinous pericarditis: Gross, natural color, close-up view of minimal fibrinous exudate on epicardial surface due to terminal renal failure
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| Image:Pericarditis 0023.jpg|Fibrinous pericarditis: Gross, natural color, anterior view of heart with mild fibrinous exudate over epicardium due to terminal renal failure
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| Image:Pericarditis 0024.jpg|Tuberculous pericarditis: Gross, natural color, shaggy hemorrhagic exudate. This case is much more hemorrhagic than the typical tuberculous pericarditis.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0025.jpg|Heart transplant: Gross, natural color, external view of heart. Two months after transplantation with fibrinous pericarditis
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| Image:Pericarditis 0026.jpg|Neoplastic pericarditis: Gross, natural color, shaggy pericarditis. Primer is adenocarcinoma of the lung.
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| Image:Pericarditis 0027.jpg|Heart: Septic pericarditis
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Hemopericardium 001.jpg|Hemopericardium: Gross, an excellent in situ view
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| Image:Hemopericardium 002.jpg|Hemopericardium: Gross, in situ, unopened pericardium (a very good example)
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| Image:Hemopericardium 003.jpg|Hemopericardium: Gross, natural color, heart in situ with opened pericardium and filled with red blood clot (quite good example) dissecting aneurysm
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Hemopericardium 004.jpg|Hemopericardium due to Needle Puncture: Gross, natural color, external view of heart covered by blood
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| Image:Hemopericardium 005.jpg|Needle Puncture Mark in Epicardium: Gross, natural color, close-up of needle puncture marks tap resulted in hemopericardium
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| Image:Hemopericardium 006.jpg|Hemopericardium: Hemopericardium caused by pericardiocentesis: Gross, natural color, close-up view of apex of the heart. Needle apparently entered the distal posterior descending artery.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Hemopericardium 007.jpg|Hemopericardium: Hemopericardium caused by pericardiocentesis: Gross, natural color, view of apex of the heart. Needle apparently entered the distal posterior descending artery
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| Image:Hemopericardium 008.jpg|Hemopericardium: Hemopericardium due to pericardiocentesis: Gross, fixed tissue, close-up view of slice through distal posterior descending artery showing periarterial hemorrhage
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| Image:Hemopericardium 009.jpg|Hemopericardium: Liver: Gross, natural color, typical shock liver case of death due to hemopericardium secondary to pericardiocentesis
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Hemopericardium 010.jpg|Hemopericardium in newborn: Gross, natural color, opened body with large collection blood in pericardial sac. Cause uncertain. A 26 week premature with hyaline membrane disease and DIC
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| Image:Hemopericardium 011.jpg|Hemopericardium: Myocardial Infarction and Ventricular Rupture
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Hemopericardium 012.jpg|Hemopericardium: Infarct rupture after 7 days of chest pain onset.
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| Image:Hemopericardium 013.jpg|Hemopericardium in dissecting aneurysm: Gross, heart with root of aorta to show hemorrhage into pericardium (very good example)
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| </gallery>
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| </div>
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| ====Microscopic Images====
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0028.jpg|Tuberculous pericarditis.
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| Image:Pericarditis 0029.jpg|Tuberculous pericarditis.
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| Image:Pericarditis 0030.jpg|Tuberculous pericarditis: Micro oil acid fast stain. The organism easily seen.
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0031.jpg|Tuberculous pericarditis: Micro oil acid fast stain. The organism easily seen.
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| Image:Pericarditis 0032.jpg|Uremic pericarditis: Micro med mag, H&E. A good example
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| Image:Pericarditis 0033.jpg|Tuberculous pericarditis: Micro med mag, H&E, a typical lesion
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Pericarditis 0034.jpg|Fibrinous pericarditis.
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| Image:Pericarditis fibrinosa.jpg|Pericarditis fibrinosa (Fibrinous pericarditis).
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| Image:Heart in mesothelial tumors 16.jpg|Malignant Mesothelioma, Biphasic Type: Pericardium: This tumor has epithelioid cells (lower half) surrounded by spindled cells. The patient was a 46-year-old woman with constrictive pericarditis; the pericardium was studded with coalescing tumor nodules.
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| </gallery>
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| </div>
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| * <Youtube v=AKS7kSl4x5k/>
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| * Acute fibrinous pericarditis
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| <Youtube v=5fz_W1YxbC8/>
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| | == [[Pericarditis natural history|Natural History, Complications and Prognosis]] == |
| | [[Pericardial effusion|Pericardial Effusion]] | [[Cardiac tamponade|Cardiac Tamponade]] | [[Constrictive pericarditis|Constrictive Pericarditis]] |
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| | ==Diagnosis== |
| | [[Pericarditis history and symptoms|History and Symptoms]] | [[Pericarditis physical examination|Physical Examination]] | [[Pericarditis laboratory studies|Laboratory Findings]] | [[Pericarditis electrocardiogram|Electrocardiogram]] | [[Pericarditis EKG examples|EKG Examples]] | [[Pericarditis chest x ray|Chest X Ray]] | [[Pericarditis MRI|MRI]] | [[Pericarditis CT|CT]] | [[Pericarditis echocardiography|Echocardiography]] | [[Pericarditis other imaging findings|Other Imaging Findings]] |
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| == Treatment == | | == Treatment == |
| | [[Pericarditis treatment|Medical Therapy]] | [[Pericardiocentesis]] | [[Pericardial window|Pericardial Window]] | [[Pericardial stripping|Pericardial Stripping]] | [[Treatment Related Videos]] |
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| The majority of patients with pericarditis are hospitalized so they can be observed and monitored for complications while they recover. The treatment of viral or idiopathic pericarditis is with [[non-steroidal anti-inflammatory drug]]s. Patients should be observed for side effects since [[NSAID]]s are known to effect the GI mucosa.
| | == Case Studies == |
| | | [[Pericarditis case study one|Case #1]] |
| Severe cases of pericarditis may require:
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| * [[pericardiocentesis]]
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| * [[antibiotic]]s
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| * [[steroid]]s
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| * [[colchicine]]
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| * [[surgery]]
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| Patients with uncomplicated acute pericarditis can generally be treated and followed up in an outpatient clinic. However, those with high risk factors for developing complications (see above) will need to be admitted to an inpatient service, most likely an ICU setting. High risk patients include:<!--
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| --><ref name="imazio2">{{cite journal | author= Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R | title= Day-hospital treatment of acute pericarditis: a management program for outpatient therapy | journal= J Am Coll Cardiol | year=2004 | pages=1042–6 | volume=43 | issue=6 | pmid=15028364 | doi= 10.1016/j.jacc.2003.09.055}}</ref>
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| * subacute onset
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| * high fever (> 100.4 F) and [[leukocytosis]]
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| * development of [[cardiac tamponade]]
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| * large [[pericardial effusion]] (echo-free space > 20 mm) resistant to [[NSAID]] treatment
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| * immunocompromised
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| * history of oral anticoagulation therapy
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| * acute trauma
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| * failure to respond to seven days of NSAID treatment.
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| ===Usual Steps in Treatment of Pericarditis===
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| '''''[[Pericardiocentesis]]''''' is a procedure whereby the fluid in a pericardial effusion is removed through a needle. It is performed under the following conditions:<!--
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| --><ref name="maisch2">{{cite journal | author= Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH | title= Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology | journal= Eur Heart J | year=2004 | pages=587–10 | volume=25 | issue=7 | pmid=15120056 | doi= 10.1016/j.ehj.2004.02.002}}</ref>
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| * presence of moderate or severe cardiac tamponade
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| * diagnostic purpose for suspected purulent, tuberculosis, or neoplastic pericarditis
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| * persistent symptomatic pericardial effusion
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| '''''[[NSAIDs]]''''' in ''viral'' or ''idiopathic'' pericarditis. In patients with underlying causes other than viral, the specific etiology should be treated. With idiopathic or viral pericarditis, NSAID is the mainstay treatment. Goal of therapy is to reduce pain and inflammation. The course of the disease may not be affected. The preferred NSAID is [[ibuprofen]] because of rare side effects, better effect on coronary flow, and larger dose range.<!--
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| --><ref name="maisch2">{{cite journal | author= Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH | title= Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology | journal= Eur Heart J | year=2004 | pages=587–10 | volume=25 | issue=7 | pmid=15120056 | doi= 10.1016/j.ehj.2004.02.002}}</ref> Depending on severity, dosing is between 300-800 mg every 6-8 hours for days or weeks as needed. An alternative protocol is [[aspirin]] 800 mg every 6-8 hours.<!--
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| --><ref name="imazio2">{{cite journal | author= Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R | title= Day-hospital treatment of acute pericarditis: a management program for outpatient therapy | journal= J Am Coll Cardiol | year=2004 | pages=1042–6 | volume=43 | issue=6 | pmid=15028364 | doi= 10.1016/j.jacc.2003.09.055}}</ref> Dose tapering of NSAIDs may be needed. In pericarditis following acute myocardial infarction, NSAIDs other than aspirin should be avoided since they can impair scar formation. As with all NSAID use, GI protection should be engaged. Failure to respond to NSAIDs within one week (indicated by persistence of fever, worsening of condition, new pericardial effusion, or continuing chest pain) likely indicates that a cause other than viral or idiopathic is in process.
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| '''''[[Colchicine]]''''' can be used alone or in conjunction with NSAIDs in prevention of recurrent pericarditis and treatment of recurrent pericarditis. For patients with a first episode of acute idiopathic or viral pericarditis, they should be treated with an NSAID plus colchicine 2 mg on first day followed by 1 mg daily [http://circ.ahajournals.org/cgi/content/full/113/12/1622] for three months. <!--
| |
| --><ref name="adler">{{cite journal | author= Adler Y, Zandman-Goddard G, Ravid M, Avidan B, Zemer D, Ehrenfeld M, Shemesh J, Tomer Y, Shoenfeld Y | title= Usefulness of colchicine in preventing recurrences of pericarditis | journal= Am J of Cardiol | year=1994| pages=916–7 | volume=73 | issue=12 | pmid=8184826 | doi= 10.1016/0002-9149(94)90828-1}}</ref><!--
| |
| --><ref name="imazio3">{{cite journal | author= Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R | title= Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial | journal= Circulation | year=2005| pages=2012–6 | volume=112 | issue=13 | pmid=16186437 | doi= 10.1161/CIRCULATIONAHA.105.542738}}</ref><!--
| |
| --><ref name="imazio4">{{cite journal | author= Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R | title= Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial | journal= Arch Intern Med | year=2005| pages=1987–91 | volume=165 | issue=17 | pmid=16186468 | doi= 10.1001/archinte.165.17.1987}}</ref>
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| '''''[[Corticosteroids]]''''' are usually used in those cases that are clearly refractory to NSAIDs and colchicine and a specific cause has not been found. Systemic corticosteroids are usually reserved for those with autoimmune disease.
| |
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| == Pharmacotherapy ==
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| === Acute Pharmacotherapies ===
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| As previously mentioned, the typical pharmacotherapy in viral or idiopathic pericarditis is with [[NSAID]]s. These drugs have analgesic, antipyretic and anti-inflammatory effects. The most prominent members of this group of drugs are [[aspirin]] and [[ibuprofen]]. [[Paracetamol]] ([[acetaminophen]]) has negligible anti-inflammatory activity.
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| === Chronic Pharmacotherapies ===
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| Severe cases may require one of the aforementioned procedures or one of the alternative pharmacotherapies listed below:
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| :* Antibiotics
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| :* Steroids
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| ==Surgical and Device Based Therapies==
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| ===[[Pericardiocentesis]]===
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| ===[[A thoracoscopic approach to creating a pericardial window]]===
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| ===[[A surgical subxiphoid incision to create a pericardial window]]===
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| === Pericardial Stripping for Constrictive Pericarditis===
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| The definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire [[pericardium]] is peeled away from the heart. This may be effective in up to 50% of patients. This procedure has significant risk involved, since the thickened [[pericardium]] is often adherent to the [[myocardium]] and coronary arteries.
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| In patients who have undergone [[coronary artery bypass surgery]] with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium. If any pericardium is not removed, it is possible for bands of pericardium to cause localized constriction which may cause symptoms and signs consistent with constriction.
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| ===Treatment Related Videos===
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| * <youtube v=lJ6KzpnjbRg/>
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| ==Complications==
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| ===Fibrinous pericarditis===
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| [[Image:Pericarditis fibrinosa.jpg|thumb|150px|left|Pericarditis fibrinosa]]
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| Fibrinous pericarditis is an [[exudative]] [[inflammation]].
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| The pericardium is infiltrated by the fibrinous exudate. This consists of [[fibrin]] strands and [[leukocytes]].
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| Fibrin describes an amorphous, [[eosinophilic]] (pink) network. Leukocytes (mainly [[neutrophils]]) are found within the fibrin deposits and intrapericardic.
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| Vascular congestion is also present. The myocardium has no changes. Sometimes referred to as having "Bread and Butter Appearance". Photo at: [http://www.pathologyatlas.ro/Fibrinous%20Pericarditis.html Atlas of Pathology]
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| ===Pericarditis due to tuberculosis===
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| Pericarditis caused by [[tuberculosis]] is difficult to diagnose, because definitive diagnosis requires culturing ''[[Mycobacterium tuberculosis]]'' from aspirated [[pericardium|pericardial]] fluid or pericardial [[Wiktionary:biopsy|biopsy]], which requires high technical skill and is often not diagnostic (the yield from culture is low even with optimum specimens).
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| The [[Tygerberg score|Tygerberg scoring system]] helps the clinician to decide whether pericarditis is due to tuberculosis or whether it is due to another cause:
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| * Night sweats (1 point),
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| * Weight loss (1 point),
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| * Fever (2 point),
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| * Serum globulin > 40g/l (3 points),
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| * Blood total leucocyte count <10 x 10<sup>9</sup>/l (3 points);
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| A total score of 6 or more is highly suggestive of tuberculous pericarditis.<ref>{{cite journal | author=Reuter H, Burgess L, van Vuuren W, Doubell A. | title=Diagnosing tuberculous pericarditis | journal=Q J Med | year=2006 | volume=99 | pages=827–39 | pmid=17121764 }}</ref>
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| Pericardial fluid with an [[interferon-gamma|interferon-γ]] level greater than 50[[Wiktionary:picogram|pg]]/ml is highly specific for tuberculous pericarditis.
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| The definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire pericardium is peeled away from the heart. This procedure has significant risk involved,<ref name="Cinar-2006">{{cite journal | author=Cinar B, Enc Y, Goksel O, Cimen S, Ketenci B, Teskin O, Kutlu H, Eren E. | title=Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy | journal=Int J Tuberc Lung Dis | year=2006 | volume=10 | issue=6 | pages=701–6 | pmid=16776460}}</ref> with mortality rates of 6% or higher in major referral centers.<ref name="Chowdhury-2006">{{cite journal | author=Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P | title=Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques | journal=Ann Thorac Surg | year=2006 | volume=81 | issue=2 | pages=522–9 | pmid=16427843 | doi=10.1016/j.athoracsur.2005.08.009}}</ref><ref name="Ling-1999">{{cite journal | author=Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB, Tajik AJ | title=Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy | journal=Circulation | year=1999 | volume=100 | issue=13 | pages=1380–6 | pmid=10500037}}</ref> The high risk of the procedure is attributed to adherence of the thickened pericardium to the [[myocardium]] and [[coronary arteries]]. In patients who have undergone [[coronary artery bypass surgery]] with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium.
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| ==Case Examples==
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| ===Case #1===
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| ====Clinical Summary====
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| This patient is a 36-year-old white male with a history of long-standing renal disease who presents with end-stage kidney disease and a BUN of 112 mg/dL. During the present hospitalization he developed a pericardial friction rub and pericardial and pleural effusions. A semi-elective pericardiectomy was performed.
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| ====Autopsy Findings====
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| Submitted for examination was a rectangular segment of gray-tan tissue measuring 9.5 x 8.5 x 0.3 cm. The outer surface was fatty in appearance. The inner surface was rough and covered by a number of fine red papillary projections. The projections were composed of fine strands having the appearance of fibrin.
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| ====Histopathological Findings====
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| [[Image:Fibrinous pericarditis case 001.jpg|left|thumb|400px|This is a gross photograph of a heart illustrating acute fibrinous pericarditis. The pericardium on this heart has been reflected back (arrows). The surface of the heart is rough due to the deposition of fibrin on the epicardial surface of the heart and on the inner surface of the pericardium.]]
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| <br clear="left"/>
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| [[Image:Fibrinous pericarditis case 002.jpg|left|thumb|400px|This is another view of the heart with the pericardium removed. Most of the epicardial surface is covered with fibrinous deposits as in the previous slide. There are a few glistening areas of exposed normal epicardial tissue.]]
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| <br clear="left"/>
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| [[Image:Fibrinous pericarditis case 003.jpg|left|thumb|400px|This low-power photomicrograph illustrates the dark-red-staining fibrin deposits on the inner surface (arrows). This pericardium is much thicker than normal and there are numerous inflammatory cells within the pericardial tissue.]]
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| <br clear="left"/>
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| | |
| [[Image:Fibrinous pericarditis case 004.jpg|left|thumb|400px|This is a higher-power photomicrograph demonstrating fronds of fibrin (arrows) projecting from the surface of the pericardium.]]
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| <br clear="left"/>
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| | |
| [[Image:Fibrinous pericarditis case 005.jpg|left|thumb|400px|This high-power photomicrograph demonstrates fibrin (red amorphous material) on the surface of the pericardium (1). Note the reactive mesothelial cells on the surface of the pericardium (arrows) and the inflammatory cells within the pericardial tissue.]]
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| <br clear="left"/>
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| ==See Also==
| |
|
| |
|
| | == Related Chapters == |
| | * [[Chylopericardium]] |
| | * [[Congenital absence of the pericardium]] |
| * [[Hemopericardium]] | | * [[Hemopericardium]] |
| * [[Pneumopericardium]] | | * [[Pneumopericardium]] |
| * [[Chylopericardium]]
| |
| * [[Pericardial effusion]] | | * [[Pericardial effusion]] |
| * [[Congenital absence of the pericardium]]
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| * [[Pericardial window]] | | * [[Pericardial window]] |
| | * [[Cardiac tamponade]] |
| | * [[Constrictive pericarditis]] |
| * [[Pericardial sac]] | | * [[Pericardial sac]] |
| * [[Pericardial friction rub]] | | * [[Pericardial friction rub]] |
| Line 697: |
Line 53: |
| * [[Pericardium]] | | * [[Pericardium]] |
|
| |
|
| ==Source==
| | {{Circulatory system pathology}} |
| | {{WH}} |
| | {{WS}} |
|
| |
|
| * [http://www.ngc.gov/summary/summary.aspx?doc_id=4960&nbr=003524&string=Cardiac+AND+Tamponade National Guideline Clearinghouse]
| | [[Category:Medicine]] |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
| | |
| == Acknowledgements ==
| |
| The content on this page was first contributed by [[C. Michael Gibson, M.S., M.D.]]
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| | |
| ==Additional Resources==
| |
| {{refbegin|2}}
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| * Adler Y, Finkelstein Y, Guindo J, de la Serna R, Shoenfeld Y, Bayes-Genis A, Sagie A, Bayes de Luna A, Spodick DH. Colchicine treatment for recurrent pericarditis: a decade of experience. Circulation. 1998;97:2183–2185.
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| * Applegate RJ, Johnston WE, Vinten-Johansen J, Klopfenstein HS, Little WC. Restraining effect of intact pericardium during acute volume leading. Am J Physiol. 1992;262:H1725–H1733.
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| * Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayesde-Luna A, Brambilla G, Finkelstein Y, Granel B, Bayes-Genis A, Schwammenthal E, Adler Y. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multicentre all-case analysis. Eur Heart J. 2005;26:723–727.
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| * Arunasalam S, Siegel RJ. Rapid resolution of symptomatic acute pericarditis with ketorolac tromethamine: a parenteral nonsteroidal antiinflammatory agent. Am Heart J. 1993;125(pt 1):1455–1458.
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| * Bonnefoy E, Gordon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000;21:832–836.
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| * Correale E, Maggioni AP, Romano S, Ricciardiello V, Battista R, Salvarola G, Santoro E, Tognoni G, on behalf of the Gruppo Italiano perlo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI). Comparison of frequency, diagnostic and prognostic significance of pericardial involvement in acute myocardial infarction treated with and without thrombolytics. Am J Cardiol. 1993;71:1377–1381.
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| * Fowler NO. Tuberculous pericarditis. JAMA. 1991;266:99 –103.
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| * Freeman GL, LeWinter MM. Determinants of the intrapericardial pressure in dogs. J Appl Physiol. 1986;60:758 –764.
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| * Freeman GL, LeWinter MM. Pericardial adaptations during chronic cardiac dilation in dogs. Circ Res. 1984;54:294 –300.
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| * Freeman GL, Little WC. Comparison of in situ and in vitro studies of pericardial pressure-volume relation in the dog. Am J Physiol. 1986;251: H421–H427.
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| * Gunukula SR, Spodick DH. Pericardial disease in renal patients. Semin Nephrol. 2001;21:52–56.
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| * Hoit BD, Gabel M, Fowler NO. Cardiac tamponade in left ventricular dysfunction. Circulation. 1990;82:1370–1376.
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| * Imazio M, Bobbio M, Cecchi E, Demarie D, Demichellis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghiso A, Belli R, Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) Trial. Circulation. 2005;112:2012–2016.
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| * Imazio M, Demichellis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003;42:2144–2148.
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| * Imazio M, Demichellis B, Parrini I, Gluggia M, Cecchi E, Gaschino G, Demarie D, Ghislo A, Trinchero R. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43:1042–1046.
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| * Jerjes-Sanchez C, Ramirez-Rivera A, Ibarra-Perez C. The Dressler syndrome after pulmonary embolism. Am J Cardiol. 1996;78:343–345.
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| * Kansal S, Roitman D, Sheffield LT. Two-dimensional echocardiography of congenital absence of pericardium. Am Heart J. 1985;109:912–915.
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| * Klopfenstein HS, Schuchard GH, Wann LS, Palmer TE, Hartz AJ, Gross CM, Singh S, Brooks HL. The relative merits of pulsus paradoxus and right ventricular diastolic collapse in the early detection of cardiac tamponade: an experimental echocardiographic study. Circulation. 1985;71: 829–833.
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| * Knopf WD, Talley JD, Murphy DA. An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol. 1987;59:1202.
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| * Lange RA, Hillis D. Acute pericarditis. N Engl J Med. 2004;351: 2195–2202.
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| * LeWinter MM, Kabbani S. Pericardial diseases. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease. 7th ed. Philadelphia, Pa: Elsevier Saunders; 2005:1757–1780.
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| * Maisch B, Ristic D, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone. Eur Heart J. 2002;23: 1503–1508.
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| * Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH, for the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25:587– 610.
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| * Maisch B. Recurrent pericarditis: mysterious or not so mysterious? Eur Heart J. 2005;26:631– 633.
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| * Mandell BF. Cardiovascular involvement in systemic lupus erythematosus. Semin Arthritis Rheum. 1987;17:126 –141.
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| * Miyazaki T, Pride HP, Zipes DP. Prostaglandins in the pericardial fluid modulate neural regulation of cardiac electrophysiological properties. Circ Res. 1990;66:163–175.
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| * Park JH, Choo SJ, Park SW. Acute pericarditis caused by acrylic bone cement after percutaneous vertebroplasty. Circulation. 2005; 111:e98.
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| * Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56:623– 630.
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| * Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart. 2004;90:252–254.
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| * Reddy PS, Curtiss EI, O’Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation. 1978;58:265–272.
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| * Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. 1990;66:1487–1491.
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| * Shabetai R, Fowler NO, Guntheroth WG. The hemodynamics of cardiac tamponade and constrictive pericarditis. Am J Cardiol. 1970;26: 480–489.
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| * Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart. 2004; 90:255–256.
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| * Shabetai R. Recurrent pericarditis: recent advances and remaining questions. Circulation. 2005;112:1921–1923.
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| * Singh S, Wann S, Schuchard GH, Klopfenstein HS, Leimgruber PP, Keelan MH, Brooks HL. Right ventricular and right atrial collapse in patients with cardiac tamponade: a combined echocardiographic and hemodynamic study. Circulation. 1984;70:966–971.
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| * Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349: 684–690.
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| * Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003;289:1150 –1153.
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| * Spodick DH. Intrapericardial treatment of persistent autoreactive pericarditis / myopericarditis and pericardial effusion. Eur Heart J. 2002;23: 1481–1482.
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| * Spodick DH. Macrophysiology, microphysiology, and anatomy of the pericardium: a synopsis. Am Heart J. 1992;124:1046 –1051.
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| * Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;363: 717–727.
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| * Tsang TS, Barnes ME, Hayes SN, Freeman WK, Dearani JA, Butler SL, Seward JB. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979–1998. Chest. 1999;116:322–331.
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| * Tsang TS, Oh JK, Seward JB, Tajik AJ. Diagnostic value of echocardiography in cardiac tamponade. Herz. 2000;25:734–740.
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| * Zayas R, Anguita M, Torres F, Gimenez D, Bergillos F, Ruiz M, Ciudad M, Gallardo A, Valles F. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75:378 –382.
| |
| {{refend}}
| |
| | |
| == Suggested Links and Web Resources ==
| |
| * [http://www.mayoclinic.com/invoke.cfm?objectid=CE3BC2CF-B4C1-4401-8F0F9E0B7C284538&dsection=1 Pericarditis] - Mayo Clinic series
| |
| * [http://cardiologychannel.com/pericarditis/diagnosis.shtml Pericarditis] - cardiologychannel.com
| |
| * [http://heartcenter.seattlechildrens.org/conditions_treated/pericarditis.asp Pericarditis information] from Seattle Children's Hospital Heart Center
| |
| * [http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2002;volume=48;issue=1;spage=46;epage=9;aulast=Khasnis Pulsus paradoxus] - Journal of Postgraduate Medicine
| |
| * http://en.wikipedia.org/wiki/Pericarditis
| |
| * [http://www.SeeMyHeart.org SeeMyHeart] - Patient Information on Echocardiograms (Heart Ultrasounds)
| |
| * [http://www.asecho.org American Society] of Echocardiography
| |
| * [http://www.ptca.org/imaging/stress_test.html Stress Test with Echocardiography] from Angioplasty.Org
| |
| * [http://heartcenter.seattlechildrens.org/what_to_expect/echocardiogram.asp Echocardiography information] from Children's Hospital Heart Center, Seattle.
| |
| * [http://know-heart-diseases.com Coronary heart disease] And echocardiography
| |
| * [http://www.echocardiology.org Echocardiography Resources] Simple echocardiography tutorials
| |
| * [http://www.manbit.com/ERS/ERSindex.asp Atlas of Echocardiography] Echocardiography Database
| |
| * [http://www2.umdnj.edu/~shindler/index.html E-chocardiography] Internet Journal of Cardiac Ultrasound
| |
| * [http://www.echobasics.de Echobasics] Basic introduction to echocardiography - German/Spanish English planned for 2007
| |
| * [http://www.mitral.com/echocardiography.shtml Echocardiography] Basic information about echocardiography - HealthwoRx
| |
| | |
| == For Patients ==
| |
| | |
| * [http://www.mssm.edu/cvi/pericarditis.shtml#q1 Pericarditis]
| |
| | |
| {{Electrocardiography}}
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| {{Circulatory system pathology}}
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