Pericarditis resident survival guide

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

Overview

Acute pericarditis refers to inflammation of the pericardial sac, which can be dry, fibrinous or effusive, independent from its aetiology. The term myopericarditis, or perimyocarditis, is used for cases of acute pericarditis that also demonstrate myocardial inflammation resulting in global or regional myocardial dysfunction, elevations of troponins, MB creatine-kinase, myoglobin and tumour necrosis factor.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Aortic dissection
• Myocardial Infarction
• Uremia

Common Causes

• Autoimmune: Rheumatoid arthritis, Sjögren’s syndrome, SLE, systemic sclerosis, systemic vasculitis
• Bacterial: Coxiella burnetii, pneumococcus, staphylococcus, streptococcus, tuberculosis
• Cardiovascular: Dressler's syndrome, post-myocardial infarction syndrome, postpericardiotomy syndrome, posttraumatic pericarditis
• Neoplastic: Breast cancer, leukemia, lung cancer, lymphoma
• Viral: Adeno virus, CMV, coxsackie, EBV, echovirus, HBV, HCV, HIV, HIV, human herpes virus 6, influenza, mumps, parvovirus B19, rubella, varicella
• Metabolic: Myxedema, uremia

Management

Characterize the symptoms: Symptoms suggestive of pericarditis: ❑ Chest pain: ❑ Sudden onset ❑ Sharp or dull, aching and pressure like ❑ Pleuritic (exacerbated by inspiration and coughing) ❑ Retrosternal or radiation to neck, arms, trapezius muscle ridges ❑ Affected by position (improved by sitting up and leaning forward) ❑ No pain (uremia and tuberculosis pericarditis develop slowly) Symptoms associated with pericardial effusion: ❑ Without a hemodynamically significant pericardial effusion ❑ No specific symptoms ❑ With a hemodynamically significant pericardial effusion ❑ Fatigue ❑ Breathlessness ❑ Orthopnea ❑ Dizziness ❑ Loss of consciousness ❑ Cool extremities ❑ Peripheral cyanosis ❑ Peripheral edema Other associated symptoms: ❑ Fever ❑ Cough ❑ Palpitations ❑ Malaise ❑ Joint pains ❑ Odynophagia ❑ Weight loss Obtain a detailed history: ❑ Infections: ❑ Pneumonia ❑ Tuberculosis ❑ HIV ❑ Travel history ❑ Medications ❑ 5-Fluorouracil ❑ Amiodarone ❑ Anticoagulants ❑ Cyclosporine ❑ Cyclyphosphamide ❑ Cytarabine ❑ Daunorubicin ❑ Doxorubicin ❑ Drug-induced lupus erythematosus ❑ Methysergide ❑ Penicillins ❑ Sulfa drugs ❑ Thiazides ❑ Thrombolytic agents ❑ Systemic illness ❑ Collagen vascular disease ❑ Hypothyroidism ❑ Inflammatory bowel disease ❑ Malignancy ❑ Uremia ❑ Others ❑ Cardiac surgery ❑ Radiation exposure ❑ Post myocardial infarction ❑ Trauma history

Examine the patient: ❑ Vitals ❑ Pulse ❑ Tachycardia (usual) ❑ Bradycardia (in hypothyroidism and uremia) ❑ Pulsus paradoxus (in cardiac tamponade) ❑ Blood pressure ❑ Normal (usual) ❑ Hypotension (in cardiac tamponade) ❑ Temperature ❑ Fever less than 39°C or 102.2°F ❑ Hypothermic (in elderly and renal failure) ❑ Respiratory rate ❑ Tachypnea ❑ Cardiovascular: ❑ Heart sounds ❑ Normal (usual) ❑ Distant and muffled (in cardiac tamponade) ❑ Pericardial friction rub ❑ High pitched, scratchy or squeaky sound ❑ Best heard at the left sternal border ❑ Best heard with the diaphragm of the stethoscope ❑ Vary in intensity overtime and need reapeated examinations (https://www.youtube.com/watch?v=fI4XXFRotNE) ❑ Jugular venous pulse ❑ Elevated (in tamponade and constrictive pericarditis) ❑ Kussmaul sign (in constrictive pericarditis) ❑ Any murmer ❑ Percuss cardiac dullness ❑ Dullness beyond the apical point of maximal impulse is seen in pericardial effusion ❑ Respiratory system: ❑ Wheeze or rhales ❑ Pleural effusion ❑ Abdominal examination ❑ Pulsatile hepatomegaly (in constrictive pericarditis) ❑ Ascites

Order laboratory tests (urgent): ❑ CBC: Leucocytosis ❑ ESR: Elevated ❑ C reactive protein: Elevated ❑ Serum cardiac troponin I and T ❑ Creatine kinase: CK-MB ❑ Serum urea and creatinine Order electrocardiogram (urgent): ❑ Typical findings in pericarditis ❑ Widespread upward concave ST-segment elevation ❑ PR-segment depression ❑ Electrical alternans (in cardiac tamponade) Order imaging (urgent): ❑ Chest X-ray ❑ Cardiomegaly (pericardial effusion) ❑ Clear lung fields Pericardial effusion ❑ Echocardiography ❑ Diagnostic ❑ Pericardial effusion ❑ Circumferential ❑ Loculated ❑ Anteriorly ❑ Posteriorly ❑ Findings suggestive of cardiac tamponade on subcostal view: ❑ Collapse of the right atrium ❑ Collapse of the right ventricle ❑ Ejection fraction, valvular abnormalities

Diagnosis of acute pericarditis: Atleast two of the following criteria: ❑ Characteristic chest pain ❑ Pericardial friction rub ❑ Suggestive EKG changes ❑ New or worsening pericardial effusion

Yes

No or equivocal

❑ Acute pericarditis ❑ Myopericarditis * Elevated cardiac enzymes * Myocardial dysfunction on echo

Consider cardiac MRI (CMR)

Consider alternative diagnosis

Treat as acute pericarditis or myopericarditis if there is delayed enhancement on CMR

High risk features ❑ Fever >38°C ❑ Leucocytosis ❑ Subacute presentation ❑ Cardiac tamponade ❑ Large pericardial effusion ❑ Elevated troponins (myopericarditis) ❑ Concurrent oral anticoagulation ❑ Lack of response to aspirin or NSAIDs after at least 1 wk of therapy ❑ Immunosuppressed state ❑ Acute trauma ❑ Relapsing pericarditis

Inpatient treatment

Outpatient treatment

Stable

Unstable

Clinical testing for underlying etiology

High risk features ❑ Immediately transfer the patient to ICU ❑ Telemetry monitoring and frequent vital checks ❑ Call cardiology team immediately ❑ Cardiac tamponade management ❑ Make sure patient is oxygenating well

NSAID's ❑ High-dose aspirin: ❑ Orally 800 mg QID or TDS x 7-10 days ❑ Gradual tapering by 800 mg/week for 3 additional weeks ❑ Indomethacin: ❑ Orally 50 mg TDS x 1-2 weeks ❑ Gradual tapering every 2-3 days for Rx period of 3-4 weeks ❑ Avoid in coronary artery disease patients ❑ Ibuprofen: ❑ Orally 300-800 mg TDS or QID x 1-2 weeks ❑ Gradual tapering every 2-3 days ❑ Avoid in coronary artery disease patients ❑ Add gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) ❑ Omeprazole (20 mg/day) Colchicine ❑ Alone or in combination with NSAIDs ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Steroids ❑ Avoid steroids to treat an initial episode of pericarditis

No relapse

Relapse

Follow up ❑ 7 to 10 days to assess response to treatment ❑ At 1 month check blood tests and CRP ❑ Thereafter only if symptoms recur

Look below for management of relapsing pericarditis

Etiology Specific Management

Clinical subgroups	Specific investigations	Treatment
Viral pericarditis	* Evaluation of pericardial effusion and/or pericardial/epicardial tissue * PCR or in-situ hybridisation	* CMV pericarditis: Hyperimmunoglobulin OD 4 ml/kg on day 0, 4,and 8; 2 ml/kg on day 12 and 16. * Coxsackie B pericarditis: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3 x per week * Adenovirus and parvovirus B19 perimyocarditis: Immunoglobulin 10 g IV at day 1 and 3 for 6-8 hours
Bacterial pericarditis	* Gram, acid-fast staining and cultures of the pericardial and body fluids	* Rinsing of the pericardial cavity, combined with antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures. * Pericardiectomy is required in patients with dense adhesions, loculated and thick purulent effusion, recurrence of tamponade, persistent infection, and progression to constriction.
Tuberculous pericarditis	* PCR of pericardial fluid * High adenosine deaminase activity and interferon gamma concentration in pericardial effusion * Pericardial biopsy * Tuberculin skin test * Enzyme-linked immunospot (ELISPOT) * Serum titres of antimyolemmal and antimyosin antibodies	* Antituberculous therapy for 6, 9, 12 months. * Pericardiectomy is warranted in the setting of persistent constrictive pericarditis. * Prednisone 60 mg/day x 4 weeks, followed by 30 mg/day x 4 weeks, 15 mg/day x 2 weeks, and 5 mg/day x 1 week.

References

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