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pericarditis

Inflammation of the pericardium. Largely a clinical & to a lesser extent, electrocardiographic diagnosis. Etiology: 1) idiopathic 2) infection, especially viral a) viral: coxsackie, varicella, influenza, HIV, hepatitis B, Epstein Barr virus b) bacterial: Staphylococcus, Streptococcus, Mycobacterium, Neisseria gonorrhoeae, Treponema pallidum (syphilis) c) fungal: Histoplasma, Candida, Blastomyces d) parasitic: Echinococcus, Cysticercus, amoeba 3) acute myocardial infarction - Dressler's syndrome onset 2-10 weeks post MI 4) metastatic neoplasm a) lung cancer b) breast cancer c) lymphoma & leukemia 5) radiation therapy a) 20% if entire pericardium is in field of radiation b) shielding of heart reduces incidence to < 3% c) may occur immediately or months later 1] up to 15-20 years later 2] pericarditis that occurs during radiation therapy generally does not preclude completion of therapy 6) chronic renal failure (uremic pericarditis) 7) connective tissue disease a) lupus erythematosus b) rheumatoid arthritis c) rheumatic fever d) polyarteritis nodosa e) scleroderma 8) pharmacologic agents a) emetine b) hydralazine c) methysergide d) procainamide e) penicillins f) warfarin g) heparin h) doxorubicin 9) autoimmune reaction weeks to months post surgery or MI 10) myxedema 11) sarcoidosis 12) amyloidosis 13) associated with severe anemia 14) associated with atrial septal defect 15) aortic dissection with leakage into pericardial sac 16) familial Mediterranean fever 17) trauma, thoracic surgery Epidemiology: 1) men affected more often than women 2) adults affected more often than children Clinical manifestations: 1) pleuritic chest pain a) generally presenting symptom b) generally sharp, pleuritic, worsened with inspiration c) may be intense, dull suggesting myocardial ischemia d) positional, relieved by sitting up, leaning forward - worsened by supine position [20] - may be worsened by deep breaths or holding breath e) the pericardium has few pain fibers f) pain generally arises from inflammation of adjacent parietal pleura g) persistent pain, hours or days in duration 2) fever 3) palpitations 4) 2-3 component pericardial friction rub on chest auscultation - may be described as scratchy systolic & diastolic auscultatory sounds - may be best heard at left sternal border independent of respirations - described as vibratory systolic murmur [20] 5) may occur two days after myocardial infarction Laboratory: 1) complete blood count: Leukocytosis 2) elevated erythrocyte sedimentation rate (ESR) 3) markers of myocardial infarction may be slightly elevated with myopericarditis [4] - especially, troponin-I 3) leukocytes in pericardial fluid Special laboratory: 1) electrocardiogram a) diffuse ST segment elevation - concave upward - generally present in all leads except aVR & V1 - days later, ST segment returns to baseline - absence of reciprocal ST segment depression b) T-wave inversion when ST segment returns to baseline c) atrial premature contractions (APC) d) atrial fibrillation e) differentiate from early repolarization variant (ERV) - pericarditis: ST/T ratio > 0.25 - ERV: ST/T ratio < 0.25 f) PR segment depression (except aVR) [4] g) electrical alternans (alternating high & low voltage QRS complexes) with large pericardial effusions h) normalization of ST, PR & T wave changes occur late i) no QT prolongation [4] j) anterior Q waves may be observed but no pathologic Q waves [4] k) no reciprocal ST segment or T-wave changes [4] 2) echocardiogram: a) identifies pericardial effusion - initial testing [20] - absence of pericardial effusion does not rule out pericarditis [4] b) right atrial inversion suggests early cardiac tamponade 3) cardiac catheterization: - useful in differentiating cardiac tamponade, restrictive cardiomyopathy & constrictive pericarditis 4) pericardiocentesis with pericardial biopsy a) rarely indicated b) diagnosis of suspected bacterial, tubercular or systemic inflammatory disease c) pericardial effusion persisting > 3 months Radiology: 1) Chest X-ray a) increased size of heart if pericardial effusion > 250 mL b) 'water-bottle' configuration Diagnostic criteria: 1) chest pain typical of pericarditis (see Clinical manifestations:) 2) pericardial friction rub 3) new ECG changes (see electrocardiogram) 4) pericardial effusion (see echocardiogram) * 2 of 4 criteria makes diagnosis of acute pericarditis [4] Differential diagnosis: 1) unstable angina, myocardial ischemia - post MI pericarditis mimics unstable angina 2) dissecting aneurysm a) sudden, severe onset of pain b) widening of mediastinum 3) pneumothorax a) sharp chest pain with dyspnea b) ECG & CXR will distinguish 4) pulmonary infarction a) evidence of DVT b) VQ scan, pulmonary angiogram to distinguish 5) esophageal disorder a) esophageal rupture b) hiatal hernia 6) constrictive pericarditis 7) abdominal disorder presenting as chest pain - biliary colic due to cholecystitis or choledocholithiasis 8) cardiac tamponade - hypotension, jugular venous distension - pulsus paradoxus (decrease in systolic blood pressure > 10 mm Hg during inspiration) [20] 9) Dressler's syndrome - onset of symptoms 2-10 weeks post myocardial infarction - pericarditis may be a manifestation of Dressler's syndrome - pleuritis, pleural effusion Complications: 1) recurrent pericarditis (28%) - lack to response to NSAIDs & treatment of initial episode with glucocorticoids increases risk of recurrence [4] 2) pericardial tamponade 3) chronic pericarditis Management: 1) hospitalize if high-risk features a) rule out myocardial infarction b) emergent pericardiocentesis if evidence of pericardial tamponade c) patients without high-risk features (fever, leukocytosis, acute trauma, abnormal cardiac enzymes, immunosuppression, oral anticoagulant use, larger pericardial effusion, evidence of cardiac tamponade) may be managed as outpatients [4] 2) pharmacologic agents a) NSAIDS - aspirin 650-975 mg PO QID - NSAID of choice when associated with MI [4] - apparently full dose aspirin plus prasugrel Ok in elderly - indomethacin 50 mg PO TID - ibuprofen 400 mg PO QID - 3-4 weeks duration b) colchicine - may combine with NSAID or alternative to NSAID if NSAID contraindicated - primary treatment [4,20] (MKSAP,NEJM), recurrence & prevention of recurrence [6,12] - most effective drug in preventing recurrence [21] - addition of colchicine to NSAID improves rates of remission & recurrence - duration of therapy 3-6 months - may use in combination with NSAID or glucocorticoid for 3-6 months [4,13] c) hemodialysis for uremic pericarditis including stage G5 chronic kidney disease d) prednisone or other glucocorticoid - severe pain refractory to NSAIDs & colchicine or contraindications to NSAIDs & colchicine - not advised for initial therapy of pericarditis - may increase risk of pericarditis recurrence [20] - avoid post myocardial infarction as glucocorticoids inhibit myocardial healing - autoimmune-mediated pericarditis [4] - uremic pericarditis not responsive to intensive hemodialysis - 40-60 mg PO QD until improved - taper by 5 mg every 3 days until 20 mg/day, then taper more slowly - steroid withdrawal results in recurrence of pain - months of therapy [4] - no benefit for tuberculous pericarditis [14] e) codeine 15-30 mg PO every 4 hours f) interleukin-1 trap rilonacept for resolution & prevention of recurrent pericarditis [19] g) non-acetylated salicylate for post-MI pericarditis h) anticoagulants are relatively contraindicated for risk of pericardial hemorrhage i) tuberculous pericarditis - four drug therapy for tuberculosis - prednisone [4] 3) bedrest until resolution of pain 4) immunotherapy - no benefit for Myvobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis [14] 5) patient education - most cases self-limited resolving in 4-6 weeks 6) follow-up: - echocardiogram if clinical signs of constrictive pericarditis Notes: - case presentation [15]

Related

causes of pericarditis pericardial effusion

Specific

constrictive pericarditis uremic pericarditis

General

pericardial disease serositis

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 383-85
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 268-70
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 50-51
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1095
  6. Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91. PMID: 16186468
  7. Khandaker MH, Espinosa RE, Nishimura RA et al Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun;85(6):572-93 PMID: 20511488
  8. Lotrionte M, Biondi-Zoccai G, Imazio M et al International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. Am Heart J. 2010 Oct;160(4):662-70. PMID: 20934560
  9. Imazio M, Brucato A, Cemin R et al Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011 Oct 4;155(7):409-14. PMID: 21873705
  10. Imazio M, Cecchi E, Ierna S et al Investigation on Colchicine for Acute Pericarditis: a multicenter randomized placebo-controlled trial evaluating the clinical benefits of colchicine as adjunct to conventional therapy in the treatment and prevention of pericarditis; study design amd rationale. J Cardiovasc Med (Hagerstown). 2007 Aug;8(8):613-7. PMID: 17667033
  11. Imazio M, Trinchero R. Triage and management of acute pericarditis. Int J Cardiol. 2007 Jun 12;118(3):286-94 PMID: 17049636
  12. Imazio M et al. for the ICAP Investigators. A randomized trial of colchicine for acute pericarditis. N Engl J Med 2013 Sep 1 PMID: 23992557 http://www.nejm.org/doi/full/10.1056/NEJMoa1208536 - Imazio M, Brucato A, Adler Y. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2014 Feb 20;370(8):781. PMID: 24552333
  13. Meyer BJ Mounting Evidence Supports Colchicine for Pericarditis. NEJM Journal Watch. May 19, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Imazio M et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): A multicentre, double- blind, placebo-controlled, randomised trial. Lancet 2014 Mar 30; PMID: 24694983 - Cacoub PP. Colchicine for treatment of acute or recurrent pericarditis. Lancet 2014 Mar 30 PMID: 24694984
  14. Mayosi BM et al. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis. N Engl J Med 2014 Sep 2 PMID: 25178809 http://www.nejm.org/doi/full/10.1056/NEJMoa1407380 - Chaisson RE and Post WS. Immunotherapy for tuberculous pericarditis. N Engl J Med 2014 Sep 2; PMID: 25178808 http://www.nejm.org/doi/full/10.1056/NEJMe1409356
  15. LeWinter MM Clinical practice. Acute pericarditis. N Engl J Med 2014; 371:2410-2416. December 18, 2014 PMID: 25517707 http://www.nejm.org/doi/full/10.1056/NEJMcp1404070
  16. Drachman DE, Dudzinski DM, Moy MP Case 27-2017 - A 32-Year-Old Man with Acute Chest Pain. N Engl J Med 2017; 377:874-882. August 31, 2017 PMID: 28854089 http://www.nejm.org/doi/full/10.1056/NEJMcpc1706111
  17. Faria D, Freitas A. Images in Clinical Medicine. Tuberculous Pericarditis. N Engl J Med 2018; 378:e27. May 17, 2018 PMID: 29768154 https://www.nejm.org/doi/full/10.1056/NEJMicm1709552
  18. Imazio M. Pericardial involvement in systemic inflammatory diseases. Heart. 2011 Nov;97(22):1882-92. PMID: 22016400
  19. Klein AL et al. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis. N Engl J Med 2020 Nov 16; [e-pub]. PMID: 33200890 https://www.nejm.org/doi/10.1056/NEJMoa2027892
  20. NEJM Knowledge+ - NEJM Knowledge+ Question of the Week. March 26, 2924 https://knowledgeplus.nejm.org/question-of-week/5082/
  21. Imazio M, Brucato A, Forno D et al Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. Heart. 2012 Jul;98(14):1078-82. PMID: 22442198 Review.