Pericarditis

2016-02-08T10:31:11Z

Sebascuevas: /* Disposition */

==Background==
===Etiology===
*Idiopathic (25-85%)
*Infection (up to 20%, including viral, bacterial, TB)
*Malignancy: heme, lung, breast
*Uremia
*Post radiation
*Connective tissue dz
*Drugs: procainamide, hydralazine, methyldopa, anticoagulants
*Cardiac injury (can see up to weeks later): post MI (Dressler's syndrome), 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 w/ sitting up/leaning forward
*[[SOB]]
**Esp if concommitant [[pleural effusion]]
*Hypotension/extremis if [[cardiac tamponade]]
*[[Fever]]
*Friction rub

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

{{ST elevation DDX}}

==Diagnosis==
===Work-Up===
*ECG
*Labs
**WBC, ESR, trop
*CXR
*Bedside Ultrasound to r/o effusion

===ECG===
[[File:ECG000026-2.jpg|thumb|Acute pericarditis with clear diffuse ST elevation and some PTa depression]]
*[[ECG]]
**Classically described to cause diffuse ST elevations
**Less reliable in post-MI pts and those w/ baseline ECG abnormalities
**May see low voltage/alternans if effusion present
**If early repol confounding interpretation check ST:T ratio
***If (ST elev)/(T height) in V6 or I >0.25 likely pericarditis

====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
|-
| +/- pulm 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]] 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
**[[Ibuprofen]] 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Glucocorticoid therapy''' for patients contraindications to [[NSAIDs]]
**[[Prednisone]] 0.2 to 0.5 mg/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 x3months
**Patients<70kg - 0.6mg PO Daily x 3 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 >2.5 mg/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]] Rx (>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]]

==References==
<references/>

[[Category:Cards]]

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Pericarditis