ACUTE PERICARDITIS


I. Etiology

  1. Idiopathic (> 40% of cases)
  2. Infectious (mostly viral)
  3. Cardiac-Recent MI, last post-MI ("Dressler syndrome"), thoracic aortic dissection, post-cardiac procedure
  4. Autoimmune (lupus, rheumatoid arthritis, arteritides, inflammatory bowel disease)
  5. Neoplasm (e.g. lung, breast, Hodgkin's lymphoma, mesothelioma)
  6. Uremia
  7. Radiation
  8. Medications-Hydralazine, isoniazid, phenytoin, rifampin, procainamide
  9. Trauma (including CPR)

II. Epidemiology and clinical features

  1. Male > female
  2. Adults > children
  3. Associated with periodic recurrences in about 25% of pts
  4. Typical presentation: constant, severe anterior chest pain with possible radiation to neck, UE, jaw, and/or back, typically relieved with leaning forward worse when supine
  5. Pericardial friction rub (specific but not sensitive)-"Squeaky" or "scratchy"; Usually heard best at end of expiration with patient seated and leaning forward with stethoscope applied firmly against left lower sternal border
  6. Potential complications
    1. Cardiac tamponade (occurs in 15% of cases of idiopathic pericarditis but up to 60% of patients with neoplastic, tuberculous, or purulent pericarditis)
    2. Restrictive pericarditis-Due to scarring of pericardium with loss of elasticity
  7. ECG findings-Click link for details
  8. Echocardiogram may show pericardial effusion
  9. CXR may show enlargement of cardiac silhouette from pericardial effusion
III. Management
  1. Initial workup when acute pericarditis is suspected: ECG, CBC w/diff, ESR, CRP, cardiac enzymes, plasma troponins (the latter are elevated in 35-50% of patients with pericarditis)
  2. Often treated as outpatient, though hospitalization considered if febrile, cardiac tamponade or large pericardial effusion, on anticoagulants, acute trauma, lack of improvement to NSAIDs, or elevated cardiac troponins
  3. NSAIDs are first-line treatment, e.g. ibuprofen 300-800mg Q6-8h (though if patient has had recent MI, aspirin 650-975mg Q6-8h is often used instead)
  4. Colchicine as an adjunctive treatment to NSAIDs
    1. NSAIDs usually x 1mo and colchicine x 3mos
    2. In an open-label study in 84 pts with first recurrence of acute pericarditis randomized to receive ASA + colchicine vs. ASA alone, 18mo incidence of recurrence was sig. lower in combination-treatment group (24% vs. 51%) (Arch. Int. Med. 165:1987, 2005--JW)
  5. Glucocorticoids may increase risk of recurrence but are sometimes used if the underlying cause of the pericarditis (e.g. autoimmune disease) warrants it.
  6. Anticoagulants are usually discontinued if possible, to reduce risk of hemopericardium
(Sources include Core Content Review in Family Medicine, 2012)