Pericarditis

Background

Causes:

1. idiopathic
2. infectious, including AIDS related
3. malignancy: heme, lung, breast
4. uremia
5. post radiation
6. connective tissue dz
7. drugs: procainamide, hydralaine, methyldopa, anticoagulants
8. cardiac injury (can see up to weeks later): post MI, trauma, aortic dissection

Diagnosis

1. usually sharp pleuritic chest pain, but can be anything
2. radiates to chest, back, trapezius ridge
3. diminish with sitting up/lean forward
4. SOB, esp if concommitant pleural effusion
5. hypotension/extremis if tamponade

Workup

EKG is virtually diagnostic

1. less reliable in post MI patients and others with baseline EKG abnormalities
2. if pt. has early repol.confounding interpretation, check (ST elev)/(T height) in V6; if >0.25 likely pericarditis

EKG progression:

1. global concave up ST elev, +/- PR depression
2. ST to baseline, big T's, PR dep
3. T wave flatten then inversion
4. return to baseline EKG

CXR, WBC, ESR, CK-MB, TN all nonspecific.

Echo will show NL wall motion

1. also useful to monitor progress

Friction rub

Differential Diagnosis

MI is the big confounder

MI	Pericarditis
no fever	fever pain varries 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

also on DDx:

CHF, PE, PTX, aortic dissection, pneumomediastinum, pleuritis

Treatment

1. Mostly supportive
2. NSAIDS for viral/idiopathic
3. Recurrent - colchicine
4. Uremic - dialysis
5. "buy time" with fluid boluses
6. Tamponade --> pericardiocentesis

(See Procedures: Pericardiocentesis)

Disposition

1. Most need admission, but if young and healthy can echo, and D/C with close f/u

Risk Stratification

HIGH RISK (admit)

1. Subacute sx (several dys-wks)
2. Fever >100.4
3. Evidence of tamponade
4. Large effusion (>20mm)
5. Immunosupressed
6. On anticoagulant
7. Acute trauma
8. Failure to respond to NSAID Rx (>7dy)

Complications

Tamponade/Effusion-see Pericardial Effusion and Tamponade

Recurrence

1. usually weeks to months after initial episode
2. management is same

Contrictive Pericarditis

1. restrictive picture with pericardial calcific on CXR and thicken on ECHO
2. Rx window

Source

Adapted from Pani, Donaldson, and UpToDate