Pericarditis

Background

Causes:

1. Idiopathic
2. Infection
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. Pleuritic chest pain
   1. Radiates to chest, back, trapezius
   2. Diminishes w/ sitting up/leaning forward
2. SOB
   1. Esp if concommitant pleural effusion
3. Hypotension/extremis if tamponade
4. Friction rub

Workup

ECG

• Less reliable in post MI pts and those w/ baseline ECG abnormalities
• If pt has early repol confounding interpretation check (ST elev)/(T height) in V6
  • if >0.25 likely pericarditis

ECG 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, Trop all nonspecific

DDX

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

• 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

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

• 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 Echo
• Rx with pericardial window

Source

Adapted from Pani, Donaldson, and UpToDate