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

The following is an algorithm depicting the management of acute pericarditis in adults.

Characterize the Clinical, EKG and imaging findings ❑ Characteristic chest pain ❑ Sharp and pleuritic that is improved by sitting up and leaning forward ❑ Pericardial friction rub ❑ High pitched, scratchy sound at the left sternal border best heard with diaphragm of the stethoscope ❑ Heard during atrial systole, ventricular systole and rapid ventricular filling during early diastole ❑ Suggestive EKG changes ❑ Diffuse ST elevation with reciprocal ST depression in leads aVR and V1 ❑ Suggestive echocardiography changes ❑ New or worsening pericardial effusion

Consider a possible diagnosis of acute pericarditis

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 ❑ Travel to Central or South America (Chagas disease) ❑ Travel to Central Asia or South Africa (Tuberculosis) ❑ Travel to North and Central America (Ohio and Mississippi River valleys) (Histoplasmosis) ❑ Travel to North America (Blastomycosis) ❑ 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 ❑ Dressler's syndrome ❑ Postpericardiotomy syndrome ❑ 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 {{#ev:youtube|watch?v=EUCp_3_vwtw|300}} ❑ Jugular venous pulse ❑ Elevated (in cardiac tamponade and constrictive pericarditis) ❑ Kussmaul sign (in constrictive pericarditis) ❑ Any murmur ❑ Percuss cardiac dullness ❑ Dullness beyond the apical point of maximal impulse is seen in pericardial effusion ❑ Respiratory system: ❑ Wheeze or rales ❑ 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 ❑ ST segment elevation in leads I, II, aVL, aVF, and V3-V6 ❑ PR-segment depression ❑ Low-voltage QRS complexes (in large pericardial effusion and constrictive pericarditis) Above EKG shows ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis ❑ Electrical alternans (in cardiac tamponade) Order imaging (urgent): ❑ Chest X-ray ❑ A flask-shaped, enlarged cardiac silhouette (pericardial effusion and cardiac tamponade) ❑ Clear lung fields Pericardial effusion ❑ Echocardiography ❑ Diagnostic ❑ Presence of moderate and large pericardial effusion ❑ Right atrial collapse ❑ Diastolic collapse of right ventricle and left atrium (specific for cardiac tamponade) ❑ Valvular abnormalities and masses

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 * Global or focal myocardial dysfunction on echo

Consider cardiac MRI (CMR)

Consider alternative diagnosis and treat accordingly

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

Yes

No

Inpatient treatment

Outpatient treatment

Stable

Unstable

No pre-existing coronary artery disease

Pre-existing coronary artery disease

❑ NSAID's or aspirin ❑ Colchicine may be used in recurrent or refractory disease ❑Clinical testing for underlying etiology

High risk features ❑ Immediately transfer the patient to ICU ❑ Telemetry monitoring and frequent vital checks ❑ Call cardiology team immediately ❑ Management of cardiac tamponade management ❑ Make sure patient is oxygenating well ❑ Clinical testing for underlying etiology ❑ NSAID's or aspirin ❑ Colchicine

NSAID's ❑ 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 Or ❑ 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

Aspirin ❑ High-dose aspirin: ❑ Orally 800 mg QID or TDS x 7-10 days ❑ Gradual tapering by 800 mg/week for 3 additional weeks ❑ Add gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) ❑ Omeprazole (20 mg/day) ❑ Stop anticoagulants if patient develops pericardial effusion Steroids ❑ Avoid steroids to treat an initial episode of pericarditis

Response to Rx

Yes

No

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

Hospital admission ❑ Indication that the underlying cause may not be viral or idiopathic in nature. ❑ Inpatient therapy ❑ Etiology specific management

Etiology Specific Management

Clinical subgroups	Specific investigations	Treatment
Viral pericarditis	❑ Diagnostic pericardiocentesis  :❑ 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	❑ Diagnostic pericardiocentesis  :❑ Gram stain, acid fast stain, fungal stain, and cultures of the pericardial fluid  :❑ Protein, glucose and cell count ❑ Gram stain, acid fast stain, fungal stain, and cultures of other body fluids	❑ Therapeutic pericardiocentesis or pericardial window ❑ Pericardiectomy may be used in treatment of recurrent pericardial efussion and in patients with dense adhesions, loculated and thick purulent effusion ❑ Antimicrobial therapy  :❑ Intiate antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures  :❑ Empiric regimen can be started for the following  ::❑ Immunosuppression  ::❑ Concurrent infection at another body site  ::❑ Presence of intravascular lines or prosthetic devices  ::❑ Recent antimicrobial therapy ❑ Antifungal therapy
Tuberculous pericarditis	❑ CT scan and/or MRI of the chest ❑ Culture of sputum, gastric aspirate, and/or urine ❑ Diagnostic pericardiocentesis in all suspected tuberculous pericarditis patients  :❑ PCR of pericardial fluid :❑ High adenosine deaminase activity and interferon gamma concentration in pericardial effusion ❑ Pericardial biopsy (rapid diagnosis) ❑ Tuberculin skin test (not helpful) ❑ Enzyme-linked immunospot (ELISPOT) ❑ Serum titres of antimyolemmal and antimyosin antibodies	❑Anti-tuberculosis chemotherapy  :❑ Emperic therapy in TB endemic areas and in cases with high clinical suspicion ❑ Pericardiectomy is warranted in the setting of persistent constrictive pericarditis or when no general improvement after 4-8 weeks following antituberculosis chemotherapy ❑ Prednisone can be used.
Neoplastic pericarditis	❑ CT scan and/or MRI of the chest ❑ Diagnostic pericardiocentesis ❑ Pericardial biopsy	❑ Systemic antineoplastic treatment ❑ Assess the life expectancy of the patients before proceeding with the treatment  :❑ Better prognosis patients should be treated more aggressively  :❑ Advanced malignancy should be treated palliatively with pericardiocentesis  :❑ Recurrence of pericardial effusion is prevented using any of the following techniques  ::❑ Prolonged pericardiocentesis  ::❑ Pericardial sclerosis  ::❑ Pericardiotomy  ::❑ Intrapericardial chemotherapy
Pericarditis in renal failure	❑ Renal function test ❑ Diagnostic pericardiocentesis ❑ Pericardial biopsy	❑ Uremic pericarditis  :❑ Hemodialysis or peritoneal dialysis  :❑ Heparin-free haemodialysis should be used ❑ Dialysis-associated pericarditis  :❑ Pericardiocentesis for large effusion  :❑ Pericardiotomy in non resolving effusion

References

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