WikEM - User contributions [en]

Pericarditis

2016-09-15T22:17:55Z

Jordanjm2: added etiology specific risk of constrictive pericarditis

==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*[[Uremia]]
*Post radiation
*Connective tissue disease
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>

==Clinical Features==
*Pleuritic [[chest pain]]
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub

==Differential Diagnosis==
*[[CHF]]
*[[PE]]
*[[Pneumothorax]]
*[[Aortic dissection]]
*[[Pneumomediastinum]]
*[[Pleuritis]]

{{ST elevation DDX}}

==Evaluation==
===Work-Up===
*[[ECG]]
*Labs
**WBC, CMP, ESR, CRP, trop
**Consider TSH, ANA based on clinical suspicion
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
====Classical Teachings with Caveats Below====
*Must differentiate from [[STEMI]] (classical teachings are not specific enough to do that)
*Classically pericarditis has diffuse ST-elevations
**However, pericarditis may generate localized ST-elevations
**Pericarditis '''should never produce ST-depressions''' (suggestive of reciprocal changes), except in V1 and aVR
*Classically pericardidits has concave upwards STE
**However, [[STEMI]] may have concave upwards ST-segment morphology as well
**Rather, it is '''STE convex upwards or horizontal''' that favors [[STEMI]]
*Classically pericardititis has PR-depression in ''viral pericarditis'' (or PR-elevation in AVR)
**Less reliable in post-MI patients and those with baseline ECG abnormalities
**PR-depression is often early and transient in pericarditis
**In [[STEMI]], PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis<ref>Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.</ref>
**PR-elevation in aVR may also be present in [[STEMI]] and is infrequently seen in constrictive pericarditis

====Other Findings====
*Leads II and III
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.</ref>

====Stages of Progression====
[[File:Stadia pericarditis.png|thumb|Stages of pericarditis]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
*Stage II:
**"pseudonormalisation," ST to baseline, big T's, PR dep
*Stage III:
**T wave flatten then inversion
*Stage IV:
**Return to baseline

===[[STEMI]] vs [[Pericarditis]]===
{| class="wikitable"
|-
| '''[[MI]]'''
| '''[[Pericarditis]]'''
|-
| no fever
|
fever

pain varies w/motion

|-
| focal ST chgs
| diffuse ST elev
|-
| reciprocal chgs
| no reciprocal chgs
|-
| Q waves
| no Q wave
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}

==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)'''first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Cholchicine''' add cholchicine to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''Glucocorticoid therapy''' second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to [[NSAIDs]] or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week. Also used for etiologies that are steroid responsive diseases.
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>

===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.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.</ref>

*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Life expectancy ≤18 months
*Pregnancy or lactation

===Uremic Pericarditis===
*The definitive treatment is dialysis

===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires [[Pericardiocentesis]]

==Disposition==
*Hospitalization is not necessary in most cases
*Consider admission for:
**Patients likely to have a specific cause (i.e. uremia, malignancy)
**Subacute onset over weeks
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Cardiac tamponade
**Immunosupressed
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes (suggesting myopericarditis)
**Trauma

==Complications==
*[[Pericardial Effusion and Tamponade]]
*Recurence
**Usually weeks to months after initial episode
**Management is same
*Constrictive Pericarditis
**Related to etiology; increased risk with bacterial pericarditis, rare with viral/idiopathic etiology
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window

==See Also==
*[[ST segment elevation]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]

==References==
<references/>

[[Category:Cardiology]]

Pericarditis

2016-09-15T22:15:16Z

Jordanjm2: added additional considerations for admission

==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*[[Uremia]]
*Post radiation
*Connective tissue disease
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>

==Clinical Features==
*Pleuritic [[chest pain]]
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub

==Differential Diagnosis==
*[[CHF]]
*[[PE]]
*[[Pneumothorax]]
*[[Aortic dissection]]
*[[Pneumomediastinum]]
*[[Pleuritis]]

{{ST elevation DDX}}

==Evaluation==
===Work-Up===
*[[ECG]]
*Labs
**WBC, CMP, ESR, CRP, trop
**Consider TSH, ANA based on clinical suspicion
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
====Classical Teachings with Caveats Below====
*Must differentiate from [[STEMI]] (classical teachings are not specific enough to do that)
*Classically pericarditis has diffuse ST-elevations
**However, pericarditis may generate localized ST-elevations
**Pericarditis '''should never produce ST-depressions''' (suggestive of reciprocal changes), except in V1 and aVR
*Classically pericardidits has concave upwards STE
**However, [[STEMI]] may have concave upwards ST-segment morphology as well
**Rather, it is '''STE convex upwards or horizontal''' that favors [[STEMI]]
*Classically pericardititis has PR-depression in ''viral pericarditis'' (or PR-elevation in AVR)
**Less reliable in post-MI patients and those with baseline ECG abnormalities
**PR-depression is often early and transient in pericarditis
**In [[STEMI]], PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis<ref>Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.</ref>
**PR-elevation in aVR may also be present in [[STEMI]] and is infrequently seen in constrictive pericarditis

====Other Findings====
*Leads II and III
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.</ref>

====Stages of Progression====
[[File:Stadia pericarditis.png|thumb|Stages of pericarditis]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
*Stage II:
**"pseudonormalisation," ST to baseline, big T's, PR dep
*Stage III:
**T wave flatten then inversion
*Stage IV:
**Return to baseline

===[[STEMI]] vs [[Pericarditis]]===
{| class="wikitable"
|-
| '''[[MI]]'''
| '''[[Pericarditis]]'''
|-
| no fever
|
fever

pain varies w/motion

|-
| focal ST chgs
| diffuse ST elev
|-
| reciprocal chgs
| no reciprocal chgs
|-
| Q waves
| no Q wave
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}

==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)'''first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Cholchicine''' add cholchicine to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''Glucocorticoid therapy''' second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to [[NSAIDs]] or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week. Also used for etiologies that are steroid responsive diseases.
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>

===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.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.</ref>

*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Life expectancy ≤18 months
*Pregnancy or lactation

===Uremic Pericarditis===
*The definitive treatment is dialysis

===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires [[Pericardiocentesis]]

==Disposition==
*Hospitalization is not necessary in most cases
*Consider admission for:
**Patients likely to have a specific cause (i.e. uremia, malignancy)
**Subacute onset over weeks
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Cardiac tamponade
**Immunosupressed
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes (suggesting myopericarditis)
**Trauma

==Complications==
*[[Pericardial Effusion and Tamponade]]
*Recurence
**Usually weeks to months after initial episode
**Management is same
*Contrictive Pericarditis
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window

==See Also==
*[[ST segment elevation]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]

==References==
<references/>

[[Category:Cardiology]]

Pericarditis

2016-09-15T22:11:48Z

Jordanjm2: modified meds

==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*[[Uremia]]
*Post radiation
*Connective tissue disease
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>

==Clinical Features==
*Pleuritic [[chest pain]]
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub

==Differential Diagnosis==
*[[CHF]]
*[[PE]]
*[[Pneumothorax]]
*[[Aortic dissection]]
*[[Pneumomediastinum]]
*[[Pleuritis]]

{{ST elevation DDX}}

==Evaluation==
===Work-Up===
*[[ECG]]
*Labs
**WBC, CMP, ESR, CRP, trop
**Consider TSH, ANA based on clinical suspicion
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
====Classical Teachings with Caveats Below====
*Must differentiate from [[STEMI]] (classical teachings are not specific enough to do that)
*Classically pericarditis has diffuse ST-elevations
**However, pericarditis may generate localized ST-elevations
**Pericarditis '''should never produce ST-depressions''' (suggestive of reciprocal changes), except in V1 and aVR
*Classically pericardidits has concave upwards STE
**However, [[STEMI]] may have concave upwards ST-segment morphology as well
**Rather, it is '''STE convex upwards or horizontal''' that favors [[STEMI]]
*Classically pericardititis has PR-depression in ''viral pericarditis'' (or PR-elevation in AVR)
**Less reliable in post-MI patients and those with baseline ECG abnormalities
**PR-depression is often early and transient in pericarditis
**In [[STEMI]], PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis<ref>Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.</ref>
**PR-elevation in aVR may also be present in [[STEMI]] and is infrequently seen in constrictive pericarditis

====Other Findings====
*Leads II and III
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.</ref>

====Stages of Progression====
[[File:Stadia pericarditis.png|thumb|Stages of pericarditis]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
*Stage II:
**"pseudonormalisation," ST to baseline, big T's, PR dep
*Stage III:
**T wave flatten then inversion
*Stage IV:
**Return to baseline

===[[STEMI]] vs [[Pericarditis]]===
{| class="wikitable"
|-
| '''[[MI]]'''
| '''[[Pericarditis]]'''
|-
| no fever
|
fever

pain varies w/motion

|-
| focal ST chgs
| diffuse ST elev
|-
| reciprocal chgs
| no reciprocal chgs
|-
| Q waves
| no Q wave
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}

==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)'''first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Cholchicine''' add cholchicine to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''Glucocorticoid therapy''' second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to [[NSAIDs]] or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week. Also used for etiologies that are steroid responsive diseases.
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>

===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.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.</ref>

*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Life expectancy ≤18 months
*Pregnancy or lactation

===Uremic Pericarditis===
*The definitive treatment is dialysis

===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires [[Pericardiocentesis]]

==Disposition==
*Hospitalization is not necessary in most cases
*Consider admission for:
**Subacute onset over weeks
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Immunosupressed
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes

==Complications==
*[[Pericardial Effusion and Tamponade]]
*Recurence
**Usually weeks to months after initial episode
**Management is same
*Contrictive Pericarditis
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window

==See Also==
*[[ST segment elevation]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]

==References==
<references/>

[[Category:Cardiology]]

Pericarditis

2016-09-15T22:06:48Z

Jordanjm2: modified to show NSAIDS+ colchicine as 1st line therapy

==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*[[Uremia]]
*Post radiation
*Connective tissue disease
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>

==Clinical Features==
*Pleuritic [[chest pain]]
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub

==Differential Diagnosis==
*[[CHF]]
*[[PE]]
*[[Pneumothorax]]
*[[Aortic dissection]]
*[[Pneumomediastinum]]
*[[Pleuritis]]

{{ST elevation DDX}}

==Evaluation==
===Work-Up===
*[[ECG]]
*Labs
**WBC, CMP, ESR, CRP, trop
**Consider TSH, ANA based on clinical suspicion
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
====Classical Teachings with Caveats Below====
*Must differentiate from [[STEMI]] (classical teachings are not specific enough to do that)
*Classically pericarditis has diffuse ST-elevations
**However, pericarditis may generate localized ST-elevations
**Pericarditis '''should never produce ST-depressions''' (suggestive of reciprocal changes), except in V1 and aVR
*Classically pericardidits has concave upwards STE
**However, [[STEMI]] may have concave upwards ST-segment morphology as well
**Rather, it is '''STE convex upwards or horizontal''' that favors [[STEMI]]
*Classically pericardititis has PR-depression in ''viral pericarditis'' (or PR-elevation in AVR)
**Less reliable in post-MI patients and those with baseline ECG abnormalities
**PR-depression is often early and transient in pericarditis
**In [[STEMI]], PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis<ref>Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.</ref>
**PR-elevation in aVR may also be present in [[STEMI]] and is infrequently seen in constrictive pericarditis

====Other Findings====
*Leads II and III
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.</ref>

====Stages of Progression====
[[File:Stadia pericarditis.png|thumb|Stages of pericarditis]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
*Stage II:
**"pseudonormalisation," ST to baseline, big T's, PR dep
*Stage III:
**T wave flatten then inversion
*Stage IV:
**Return to baseline

===[[STEMI]] vs [[Pericarditis]]===
{| class="wikitable"
|-
| '''[[MI]]'''
| '''[[Pericarditis]]'''
|-
| no fever
|
fever

pain varies w/motion

|-
| focal ST chgs
| diffuse ST elev
|-
| reciprocal chgs
| no reciprocal chgs
|-
| Q waves
| no Q wave
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}

==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)'''first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Cholchicine''' add cholchicine to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''Glucocorticoid therapy''' second line agent, can consider low-moderate doses for patients with contraindications to [[NSAIDs]] or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>

===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.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.</ref>

*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Life expectancy ≤18 months
*Pregnancy or lactation

===Uremic Pericarditis===
*The definitive treatment is dialysis

===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires [[Pericardiocentesis]]

==Disposition==
*Hospitalization is not necessary in most cases
*Consider admission for:
**Subacute onset over weeks
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Immunosupressed
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes

==Complications==
*[[Pericardial Effusion and Tamponade]]
*Recurence
**Usually weeks to months after initial episode
**Management is same
*Contrictive Pericarditis
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window

==See Also==
*[[ST segment elevation]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]

==References==
<references/>

[[Category:Cardiology]]

Pericarditis

2016-09-15T21:50:35Z

Jordanjm2: added minor additional diagnostic considerations

==Background==
[[File:Pericarditis.jpg|thumbnail|Pericarditis compared with normal pericardium]]
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*[[Uremia]]
*Post radiation
*Connective tissue disease
*Drugs: [[procainamide]], [[hydralazine]], methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post [[MI]] (Dressler's syndrome), [[thoracic trauma]], [[aortic dissection]]
*Troponin elevation may indicate a concurrent [[myocarditis]] which predispose to risk of [[CHF]] or [[arrhythmias|arrhythmia]]. <ref>LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.</ref>

==Clinical Features==
*Pleuritic [[chest pain]]
**Radiates to chest, back, left trapezius
**Diminishes with sitting up/leaning forward
*[[shortness of breath]]
**Especiallyif concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]], chills, myalgias (systemic signs with viral infection)
*Friction rub

==Differential Diagnosis==
*[[CHF]]
*[[PE]]
*[[Pneumothorax]]
*[[Aortic dissection]]
*[[Pneumomediastinum]]
*[[Pleuritis]]

{{ST elevation DDX}}

==Evaluation==
===Work-Up===
*[[ECG]]
*Labs
**WBC, CMP, ESR, CRP, trop
**Consider TSH, ANA based on clinical suspicion
*[[CXR]]
*Bedside Ultrasound to rule out effusion
*Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
====Classical Teachings with Caveats Below====
*Must differentiate from [[STEMI]] (classical teachings are not specific enough to do that)
*Classically pericarditis has diffuse ST-elevations
**However, pericarditis may generate localized ST-elevations
**Pericarditis '''should never produce ST-depressions''' (suggestive of reciprocal changes), except in V1 and aVR
*Classically pericardidits has concave upwards STE
**However, [[STEMI]] may have concave upwards ST-segment morphology as well
**Rather, it is '''STE convex upwards or horizontal''' that favors [[STEMI]]
*Classically pericardititis has PR-depression in ''viral pericarditis'' (or PR-elevation in AVR)
**Less reliable in post-MI patients and those with baseline ECG abnormalities
**PR-depression is often early and transient in pericarditis
**In [[STEMI]], PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis<ref>Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.</ref>
**PR-elevation in aVR may also be present in [[STEMI]] and is infrequently seen in constrictive pericarditis

====Other Findings====
*Leads II and III
**STE II > STE III favors pericarditis
**'''STE III > STE II very strongly''' favors [[STEMI]]
*STD not in aVR or V1 (reciprocol changes) suggestive of [[STEMI]]
*May see low voltage/alternans if effusion present
*If [[early repolarization]] confounding interpretation check ST:T ratio
**If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
*If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI<ref>Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.</ref>

====Stages of Progression====
[[File:Stadia pericarditis.png|thumb|Stages of pericarditis]]
[[File:Ptadepressie.png|thumb|PTa depression]]
*Stage I:
**Global concave up [[ST elevation]] in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
**PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
*Stage II:
**"pseudonormalisation," ST to baseline, big T's, PR dep
*Stage III:
**T wave flatten then inversion
*Stage IV:
**Return to baseline

===[[STEMI]] vs [[Pericarditis]]===
{| class="wikitable"
|-
| '''[[MI]]'''
| '''[[Pericarditis]]'''
|-
| no fever
|
fever

pain varies w/motion

|-
| focal ST chgs
| diffuse ST elev
|-
| reciprocal chgs
| no reciprocal chgs
|-
| Q waves
| no Q wave
|-
| +/- pulmonary edema
| clear lungs
|-
| wall motion abn
| nl wall motion
|}

==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)''' are usually first line treatment for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Cholchicine''' consider adding cholchicine to NSAIDs to prevent remission and recurrence.<ref>ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.</ref>
**Patients >70kg - 0.6mg PO BID x 3 months
**Patients<70kg - 0.6mg PO Daily x 3 months
*'''Glucocorticoid therapy''' for patients with contraindications to [[NSAIDs]]
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>

===Recurrent or Refractory===
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>Imazio M.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.</ref>

*'''[[Colchicine]]'''
**Patients >70kg - 0.6mg PO BID x 6 months
**Patients<70kg - 0.6mg PO Daily x 6 months
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Life expectancy ≤18 months
*Pregnancy or lactation

===Uremic Pericarditis===
*The definitive treatment is dialysis

===[[Pericardial effusion and tamponade|Tamponade]]===
*Tamponade requires [[Pericardiocentesis]]

==Disposition==
*Hospitalization is not necessary in most cases
*Consider admission for:
**Subacute onset over weeks
**[[Fever]] >100.4
**Large effusion (echo-free space>20mm)
**Immunosupressed
**Anticoagulant use
**Failure to respond to [[NSAID]]s (>7dy)
**Elevated cardiac enzymes

==Complications==
*[[Pericardial Effusion and Tamponade]]
*Recurence
**Usually weeks to months after initial episode
**Management is same
*Contrictive Pericarditis
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Treat with pericardial window

==See Also==
*[[ST segment elevation]]
*[[STEMI]]
*[[Myocardial_Infarction_Complications|Myocardial Infarction Complications]]
*[https://www.youtube.com/watch?v=XVCEPy5KH_w Mattu ECG Case: Sept 3, 2012 - Pericarditis vs. STEMI]

==References==
<references/>

[[Category:Cardiology]]

Nematocysts

2016-08-19T17:51:35Z

Jordanjm2: /* See Also */

==Mechanism==
*Jellyfish; Box Jelly is most deadly
*Most toxic: Australia and other Indo-Pacific waters
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
*Physical contact or osmotic gradient causes discharge of neamtocysts
*A spring loaded venom delivery system

==Clinical Features==
*Isolated stinging
*Severe
**Respiratory paralysis, cardiovascular collapse, limb paralysis and death
**Irukandji syndrome - myalgias, back, chest, abdominal pain, nausea, vomiting, diaphoresis, hypertension, tachycardia, hypertension, myocardial injury, pulmonary edema

==Differential Diagnosis==
{{Marine envenomation DDX}}

==Management==
*Remove tentacles and nematocysts
*Hot water immersion

*Consider topical lidocaine
*Consider oral or parenteral analgesia for severe pain
*Acetic Acid may inhibit or trigger nematocyst discharge and thereby increase or decrease pain depending on species

*'''Avoid urine, ethanol, ammonia'''
*'''Avoid fresh or tap water since it causes nematocyst discharge via the osmotic gradient'''

*'''Symptomatic treatment for Irukandji syndrome'''
*'''Antivenom is available for severe box-jellyfish sting'''

==See Also==
*[[Marine toxins and envenomations]]

[[Category:Environmental]][[Category:Toxicology]]

*Ward NT, Darracq MA, Tomaszewski C, et al. Evidence based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med. 2012;60(4):339-414.
*Cegolon L, Heymann WC, Lange JH, et al. Jellyfish stings and their management: a review. Mar Drugs. 2013;11(2): 523-50

Nematocysts

2016-08-19T17:51:13Z

Jordanjm2: /* See Also */

==Mechanism==
*Jellyfish; Box Jelly is most deadly
*Most toxic: Australia and other Indo-Pacific waters
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
*Physical contact or osmotic gradient causes discharge of neamtocysts
*A spring loaded venom delivery system

==Clinical Features==
*Isolated stinging
*Severe
**Respiratory paralysis, cardiovascular collapse, limb paralysis and death
**Irukandji syndrome - myalgias, back, chest, abdominal pain, nausea, vomiting, diaphoresis, hypertension, tachycardia, hypertension, myocardial injury, pulmonary edema

==Differential Diagnosis==
{{Marine envenomation DDX}}

==Management==
*Remove tentacles and nematocysts
*Hot water immersion

*Consider topical lidocaine
*Consider oral or parenteral analgesia for severe pain
*Acetic Acid may inhibit or trigger nematocyst discharge and thereby increase or decrease pain depending on species

*'''Avoid urine, ethanol, ammonia'''
*'''Avoid fresh or tap water since it causes nematocyst discharge via the osmotic gradient'''

*'''Symptomatic treatment for Irukandji syndrome'''
*'''Antivenom is available for severe box-jellyfish sting'''

==See Also==
*[[Marine toxins and envenomations]]

[[Category:Environmental]][[Category:Toxicology]]

*Ward NT, Darracq MA, Tomaszewski C, et al. Evidence based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med. 2012;60(4:339-414.
*Cegolon L, Heymann WC, Lange JH, et al. Jellyfish stings and their management: a review. Mar Drugs. 2013;11(2): 523-50

Nematocysts

2016-08-19T17:42:36Z

Jordanjm2: /* Management */

Nematocysts

2016-08-19T17:25:31Z

Jordanjm2: /* Clinical Features */

==Mechanism==
*Jellyfish; Box Jelly is most deadly
*Most toxic: Australia and other Indo-Pacific waters
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
*Physical contact or osmotic gradient causes discharge of neamtocysts
*A spring loaded venom delivery system

==Clinical Features==
*Isolated stinging
*Severe
**Respiratory paralysis, cardiovascular collapse, limb paralysis and death
**Irukandji syndrome - myalgias, back, chest, abdominal pain, nausea, vomiting, diaphoresis, hypertension, tachycardia, hypertension, myocardial injury, pulmonary edema

==Differential Diagnosis==
{{Marine envenomation DDX}}

==Management==
*Immerse in 5% acetic acid to inactivate nematocysts
*Alternatives
**Immersion in rubbing alcohol (isopropyl 40%)
**Acidic drinks such as flavored sodas and fruit juices may be helpful
**Baking soda
*'''Avoid fresh or tap water since it causes nematocyst discharge via the osmotic gradient'''
*'''Antivenom is available for severe box-jellyfish sting'''

==See Also==
*[[Marine toxins and envenomations]]

[[Category:Environmental]][[Category:Toxicology]]