Acute Pericarditis

Abstract

Acute pericarditis

Name and Synonyms

Acute pericarditis

Incidence/Epidemiology

• Acute pericarditis is the admitting diagnosis in 0.1 % of hospital admissions. Acute pericarditis accounts for 1 % of cases of ST-segment elevation seen in the emergency department.

• Acute pericarditis occurs more commonly in men than in women. There are no known geographic predilections. There is a very rare familial form (Mulibrey nanism)

Differential Diagnosis

• Acute pericarditis has many causes (see Pathophysiology and Etiology below), and often the differential exploration focuses on determining an etiology for the disease. This involves a search for co-morbidities as diverse as malignancy, renal failure, recent myocardial infarction, adverse effects of certain drugs, and collagen vascular diseases. Because the primary clinical manifestation of acute pericarditis is chest pain, the differential is broad.

Pathophysiology and Etiology

• The pathophysiology of acute pericarditis, regardless of etiology, is inflammation of the pericardium, a double (serous and parietal) membrane separated normally by 15-50 mL of fluid that is an ultrafiltrate of plasma.

• The function of the pericardium is to prevent sudden overdistention of the cardiac chambers and to help maintain the anatomic position of the heart and great vessels. By definition, acute pericarditis is present and symptomatic for less than 6 weeks; pericarditis for 6 weeks to 6 months is termed subacute, and beyond 6 months, chronic.

  • This inflammation may result from a myriad of potential causes:

    • Infectious:

      • Viral (Coxsackie, echovirus, adenovirus, HIV)

      • Tuberculous

      • Pyogenic (pneumococcal, streptococcal, staphylococcal)

      • Fungal (histoplasmosis, coccidioidomycosis, blastomycosis, Candida)

    • Noninfectious:

      • Post–myocardial infarction (Dressler’s syndrome)

      • Uremia/renal failure

      • Neoplastic (primary or metastatic [lung, breast, lymphoma, Hodgkins])

      • Myxedema

      • Trauma (penetrating or nonpenetrating)

      • Aortic dissection into pericardium

      • Post–radiation therapy

      • Rheumatic fever

      • Collagen vascular disease (lupus, rheumatoid arthritis, scleroderma, Wegener’s granulomatosis)

      • Drug-induced (procainamide, hydralazine, INH, phenytoin, doxorubicin, rifampin, methyldopa)

      • Idiopathic (most common)

Presentation

Typical/“Classic”

• Chest pain and a pericardial friction rub are most the common findings.

http://www.easyauscultation.com/acute-pericarditis[Acute Pericarditis Page; Easy Auscultation; copyright 2015, MedEdu LLC]

• On electrocardiography, there are electrical changes suggesting acute pericarditis, and if there is also an effusion there is generalized low voltage.

ECG finding in acute pericarditis [Oh J, Espinosa R. Pericardial disease. In: Vannan MA, Lang RM, Rakowski H, Tajik AJ, editors. Atlas of echocardiography. Philadelphia: Current Medicine; 2005 (Braunwald E, editor. Atlas of heart diseases; vol. 16).] Caption from original

Typical amyloid ECG with diffuse low voltage [Wellens H, Subramaniam K. The electrocardiogram in heart failure. In: Shivkumar K, Weiss JN, Fonarow GC, Narula J, editors. Atlas of electrophysiology in heart failure. Philadelphia: Current Medicine; 2005 (Braunwald E, editor. Atlas of heart diseases; vol. 15).] Caption from original

• On echocardiogram, an effusion may be visible but is not required for a diagnosis of acute pericarditis.

Echocardiogram of pericardial effusion. Arrow indicates descending thoracic aorta. [Aurigemma G, Tighe D, Oh J, Espinoza R. Pericardial disease and cardiac masses. In: Solomon SD, editor. Atlas of echocardiography. 2nd ed. Philadelphia: Current Medicine; 2008.] Caption adapted from original

Echocardiogram of pericardial effusion. Arrow indicates lung parenchyma. [Aurigemma G, Tighe D, Oh J, Espinoza R. Pericardial disease and cardiac masses. In: Solomon SD, editor. Atlas of echocardiography. 2nd ed. Philadelphia: Current Medicine; 2008.] Caption adapted from original

• If the effusion is large (>250 mL), the heart takes on a “water bottle” appearance on plain chest x-ray.

Chest X-ray in pericardial effusion: water bottle shaped heart. [Tissot C, Phelps CM, Cruz EM, Miyamoto SD. Pericardial diseases. In: Munoz R, Morell V, Cruz E, Vetterly C, editors. Critical care of children with heart disease. London: Springer; 2010. p. 521-41. https://doi.org/10.1007/978-1-84882-262-7_47; 2009-01-01] Caption from original

• Cardiac tamponade may develop, and the patient may have pulsus paradoxus.

http://www.youtube.com/watch?feature=player_embedded&v=jTsjCZ9QxW8

Stanford 25 video on pulsus paradoxus. Provides definition, guidance on testing, sound clip.

• The pain is often severe. It is most often substernal and left-sided. It often radiates to the back and to the trapezius ridge.

Trapezius ridge: the lower border of trapezius, 1; the rhomboids, 2. [Birch R. Surgical disorders of the peripheral nerves. London: Springer; 2010. Chapter 5, Clinical aspects of nerve injury; p. 145-90] Caption adapted from original

• The pain is often pleuritic in nature, so it is aggravated by deep inspiration, cough, and lying down as opposed to sitting up.

• The friction rub is the most important physical sign of acute pericarditis. It is often described as “scratching” or “grating,” and it may be evanescent. It is best heard with the diaphragm of the stethoscope along the lower left sternal border, with the patient sitting up, during exhalation.

• The classic ECG findings of acute pericarditis are diffuse, mild ST-segment elevation across the precordium. Depression of the PQ segment is common. With large effusions, the overall voltage on the ECG is reduced. Occasionally, atrial fibrillation occurs with acute pericarditis. The ST-segment elevation associated with acute pericarditis can be differentiated from simple early repolarization, and from left ventricular hypertrophy with strain, by considering the ratio of the amplitude of ST segment to the amplitude of the T wave in leads I, V4, V5, and V6.

Atypical

• The most common form of pericarditis is idiopathic, and the diagnosis is one of exclusion. Patients with acute pericarditis and no effusion may present with chest pain and no audible friction rub, with limited to no ECG changes. In this case, acute pericarditis is just one of many differential considerations in the chest pain syndrome presentation. As in other etiologies of chest pain syndrome, the pain may occur in non-substernal locations.

• Pain may be mostly absent in slowly developing pericarditis (neoplastic, uremic, postradiation). Worsening exercise intolerance may be a clue to the diagnosis in these patients.

Primary Differential Considerations

• The initial differential elements to be considered in a patient with a presentation consistent with acute pericarditis are angina, aortic dissection, pulmonary embolism, and distal esophageal pain.

History and Physical Exam

Findings That Confirm Diagnosis

• A full classic presentation (substernal and/or left-sided pleuritic chest pain, a friction rub, and diffuse mild ST-segment elevation on ECG) should be considered confirmatory and should prompt a search for an etiology other than idiopathic.

Factors That Suggest Diagnosis

• Any of the classic findings in isolation should elevate acute pericarditis in the differential diagnosis of the chest pain patient.

• Onset of pain within 2–4 days of acute myocardial infarction (Dressler’s syndrome) or after thoracic surgery should elevate acute pericarditis in the differential diagnosis of the chest pain patient.

• A presentation consistent with both acute pericarditis and an apparent cause of pericarditis (such as uremia, myxedema, acute infection, immunocompromise, collagen vascular disease, post chest irradiation) should elevate acute pericarditis in the differential diagnosis of the chest pain patient.

• Uremic pericarditis is most often seen in patients on hemodialysis (HD). A history of HD therefore is suggestive of the diagnosis. It should be noted that chest pain is often minimal or absent in uremic pericarditis, but a friction rub is common.

Factors That Exclude Diagnosis

• A normal echocardiogram excludes pericardial effusion and tamponade but not acute pericarditis.

Ancillary Studies

Laboratory

• Lab tests should include CBC; serum electrolyte, blood urea nitrogen (BUN), and creatinine levels; and erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) levels. In the evaluation of chest pain syndrome, cardiac biomarker measurements are often indicated.

• The ESR and CRP levels are elevated in acute pericarditis, consistent with the underlying inflammation. These tests also are abnormal in patients with collagen vascular diseases, which may be an etiology of acute pericarditis.

• Other laboratory tests may be pertinent to the evaluation of the etiology of the pericarditis:

  • Assessment of renal function in possible uremic pericarditis

  • Assessment of thyroid function in possible myxedema

  • An antistreptolysin O (ASO) titer is indicated if rheumatic fever is suspected.

  • If a pericardial effusion is sampled via pericardiocentesis, the fluid should be tested for cell count, glucose and protein, and culture growth. Other specialized tests may be needed, and fluid should be retained for “unusual” requests by consultants.

Echocardiographically guided pericardiocentesis procedure [Aurigemma G, Tighe D, Oh J, Espinoza R. Pericardial disease and cardiac masses. In: Solomon SD, editor. Atlas of echocardiography. 2nd ed. Philadelphia: Current Medicine; 2008.] Caption from original

https://www.youtube.com/watch?feature=player_embedded&v=BQTVqUPimdk

Video from The New England Journal of Medicine on pericardiocentesis. Covers indications, risk factors, contraindications, equipment, preparation, procedure (ultrasound-guided, electrocardiographic monitoring, and blind approaches), aftercare, and complications.

https://www.youtube.com/watch?v=y0-K2RcThi0

Video from MD Anderson Cancer Center explaining the anterior chest approach to pericardiocentesis.

Imaging

• There are no diagnostic imaging findings of acute pericarditis. When a pericardial effusion is present, transthoracic echocardiography will demonstrate an echo-free space between the visceral and parietal layers of the pericardium.

• Echocardiography should be performed in all cases of pericarditis, because any form of pericardial inflammation may induce pericardial effusion. It is important to note that in the absence of effusion, the pericardium may have a normal appearance in pericarditis.

• With large effusions, a “swinging heart” may be seen on echocardiography, as the heart “floats” in the effusion fluid.

https://www.youtube.com/watch?feature=player_embedded&v=huXuWp_eOKQ

Brief clip of cardiac tamponade with swinging heart echocardiogram.

• Plain chest radiographs are usually normal in acute pericarditis. If there is an effusion of 250 mL or more fluid, the cardiac silhouette will take on an enlarged, “water bottle” appearance.

• Smaller effusions may be detected by MRI, which can also assess the thickness of the pericardium (normal, 4 mm). In acute pericarditis, the pericardium may be globally or locally thickened.

Classic presentation of constrictive pericarditis on T1-weighted fast spin-echo CMR, axial view (a), and short-axis view (b) [From article: Cardiovascular magnetic resonance in pericardial diseases. J Cardiovasc Magn Reson. 2009; 11(1):14. https://doi.org/10.1186/1532-429X-11-14, at http://springerlink.bibliotecabuap.elogim.com/article/10.1186/1532-429X-11-14; by Jan Bogaert, Marco Francone, © Bogaert and Francone; licensee BioMed Central Ltd. 2009; licensed under Creative Commons Attribution License BY 2.0 http://creativecommons.org/licenses/by/2.0] Caption from original

Special Populations

Age

• Acute pericarditis is more common in adults than in children, but adolescents are more commonly affected than young adults

• The most common presenting complaint in children with pericarditis is chest pain, accompanied by the typical findings seen in patients of any age.

• In children, the clear majority of cases are viral in etiology, since autoimmune diseases usually present no earlier than late adolescence.

Co-morbidities

• Review of the etiologies of acute pericarditis will indicate co-morbidities of interest. Uremia, malignancy, and immunocompromise are the most worrisome of these.

Pitfalls in Diagnosis

Critical Steps Not to Miss

• Consideration of the diagnosis is the first critical step. In patients with hemodynamic compromise, an echocardiogram should be performed early to assess for effusion, or even tamponade, and to measure the pumping ability of the heart.

• Acute pericarditis is one of the few diagnoses in which an ESR and CRP are actually very helpful.

Mimics

• The entire constellation of diagnoses that underlies chest pain syndrome can mimic the pain and overall presentation of acute pericarditis.

• Because acute pericarditis is often associated with diffuse ST-segment elevation on ECG, acute coronary syndrome must be always considered as an alternative diagnosis. PR-segment depression usually is also seen in patients with acute pericarditis who have ST-segment elevation.

ECG finding in acute pericarditis [Oh J, Espinosa R. Pericardial disease. In: Vannan MA, Lang RM, Rakowski H, Tajik AJ, editors. Atlas of echocardiography. Philadelphia: Current Medicine; 2005 (Braunwald E, editor. Atlas of heart diseases; vol. 16).] Caption from original

Time-Dependent Interventions

• Time-dependent interventions in acute pericarditis are necessary only when cardiac function is compromised, which is usually the case only when there is a large pericardial effusion. In such patients, pericardiocentesis may be a life-saving procedure.

Overall Principles of Treatment

• Because acute pericarditis is an inflammatory disease, the primary treatment in idiopathic pericarditis comprises anti-inflammatory agents (such as corticosteroids [e.g., prednisone] and nonsteroidal anti-inflammatory drugs [NSAIDs]). Resistant cases may require a surgical pericardiectomy, pericardiotomy, or pericardial window.

• Patients with an identified underlying cause of their pericarditis generally benefit from better control/specific treatment of the disease.

Disease Course

• Idiopathic pericarditis generally resolves within 1-2 weeks with anti-inflammatory therapy. The recurrence rate may reach 33 %.

• The course of secondary pericarditis typically follows control of the underlying disease.

Related Evidence

Papers of particular interest have been highlighted as:

** Of key importance

Practice Guideline

Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH; Task Force on the Diagnosis and Management of Pricardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004 Apr;25(7):587-610. PMID: 15120056. http://www.ncbi.nlm.nih.gov/pubmed/15120056**

Review

Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart Fail Rev. 2013 May;18(3):355-60. https://doi.org/10.1007/s10741-012-9328-9. PMID: 22661042. http://www.ncbi.nlm.nih.gov/pubmed/22661042

Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Milinković I, Seferović Mitrović JP, Kanjuh V, Pankuweit S, Maisch B. Pericardial syndromes: an update after the ESC guidelines 2004. Heart Fail Rev. 2013 May;18(3):255-66. https://doi.org/10.1007/s10741-012-9335-x. PMID: 22855353. http://www.ncbi.nlm.nih.gov/pubmed/22855353**

Shammas NW, Padaria RF, Coyne EP. Pericarditis, myocarditis, and other cardiomyopathies. Prim Care. 2013 Mar;40(1):213-36. https://doi.org/10.1016/j.pop.2012.11.009. Epub 2012 Dec 6. PMID: 23402470. http://www.ncbi.nlm.nih.gov/pubmed/23402470**

Imazio M. Treatment of recurrent pericarditis. Expert Rev Cardiovasc Ther. 2012 Sep;10(9):1165-72. https://doi.org/10.1586/erc.12.101. PMID: 23098152. http://www.ncbi.nlm.nih.gov/pubmed/23098152**

Dudzinski DM, Mak GS, Hung JW. Pericardial diseases. Curr Probl Cardiol. 2012 Mar;37(3):75-118. https://doi.org/10.1016/j.cpcardiol.2011.10.002. PMID: 22289657. http://www.ncbi.nlm.nih.gov/pubmed/22289657**

Sheth S, Wang DD, Kasapis C. Current and emerging strategies for the treatment of acute pericarditis: a systematic review. J Inflamm Res. 2010;3:135-42. https://doi.org/10.2147/JIR.S10268. Epub 2010 Nov 25. PMID: 22096363; PMCID: PMC3218740. http://www.ncbi.nlm.nih.gov/pubmed/22096363

Lotrionte M, Biondi-Zoccai G, Imazio M, Castagno D, Moretti C, Abbate A, Agostoni P, Brucato AL, Di Pasquale P, Raatikka M, Sangiorgi G, Laudito A, Sheiban I, Gaita F. International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. Am Heart J. 2010 Oct;160(4):662-70. https://doi.org/10.1016/j.ahj.2010.06.015. PMID: 20934560. http://www.ncbi.nlm.nih.gov/pubmed/20934560

Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun;85(6):572-93. https://doi.org/10.4065/mcp.2010.0046. PMID: 20511488; PMCID: PMC2878263. http://www.ncbi.nlm.nih.gov/pubmed/20511488**

Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation. 2010 Feb 23;121(7):916-28. https://doi.org/10.1161/CIRCULATIONAHA.108.844753. PMID: 20177006. http://www.ncbi.nlm.nih.gov/pubmed/20177006**

Imazio M, Brucato A, Derosa FG, Lestuzzi C, Bombana E, Scipione F, Leuzzi S, Cecchi E, Trinchero R, Adler Y. Aetiological diagnosis in acute and recurrent pericarditis: when and how. J Cardiovasc Med (Hagerstown). 2009 Mar;10(3):217-30. https://doi.org/10.2459/JCM.0b013e328322f9b1. PMID: 19262208. http://www.ncbi.nlm.nih.gov/pubmed/19262208

Syed FF, Mayosi BM. A modern approach to tuberculous pericarditis. Prog Cardiovasc Dis. 2007 Nov-Dec;50(3):218-36. Review. PubMed PMID: 17976506. http://www.ncbi.nlm.nih.gov/pubmed/17976506

Tingle LE, Molina D, Calvert CW. Acute pericarditis. Am Fam Physician. 2007 Nov 15;76(10):1509-14. PMID: 18052017. http://www.ncbi.nlm.nih.gov/pubmed/18052017**

Ariyarajah V, Spodick DH. Acute pericarditis: diagnostic cues and common electrocardiographic manifestations. Cardiol Rev. 2007 Jan-Feb;15(1):24-30. PMID: 17172880. http://www.ncbi.nlm.nih.gov/pubmed/17172880**

Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart. 2004 Mar;90(3):252-4. PMID: 14966036; PMCID: PMC1768141. http://www.ncbi.nlm.nih.gov/pubmed/14966036

Ross AM, Grauer SE. Acute pericarditis. Evaluation and treatment of infectious and other causes. Postgrad Med. 2004 Mar;115(3):67-70, 73-5. PMID: 15038256. http://www.ncbi.nlm.nih.gov/pubmed/15038256**

Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004 Feb 28;363(9410):717-27. PMID: 15001332. http://www.ncbi.nlm.nih.gov/pubmed/15001332**

Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003 Mar 5;289(9):1150-3. PubMed PMID: 12622586. http://www.ncbi.nlm.nih.gov/pubmed/12622586**

Aikat S, Ghaffari S. A review of pericardial diseases: clinical, ECG and hemodynamic features and management. Cleve Clin J Med. 2000 Dec;67(12):903-14. PMID: 11127986. http://www.ncbi.nlm.nih.gov/pubmed/11127986

Goodman LJ. Purulent Pericarditis. Curr Treat Options Cardiovasc Med. 2000 Aug;2(4):343-350. PMID: 11096539. http://www.ncbi.nlm.nih.gov/pubmed/11096539

Clinical Trial

Imazio M, Brucato A, Barbieri A, Ferroni F, Maestroni S, Ligabue G, Chinaglia A, Cumetti D, Casa GD, Bonomi F, Mantovani F, Di Corato P, Lugli R, Faletti R, Leuzzi S, Bonamini R, Modena MG, Belli R. Good prognosis for pericarditis with and without myocardial involvement: results from a multicenter, prospective cohort study. Circulation. 2013 Jul 2;128(1):42-9. https://doi.org/10.1161/CIRCULATIONAHA.113.001531. PMID: 23709669. http://www.ncbi.nlm.nih.gov/pubmed/23709669

Cohort Study

Cakir O, Gurkan F, Balci AE, Eren N, Dikici B. Purulent pericarditis in childhood: ten years of experience. J Pediatr Surg. 2002 Oct;37(10):1404-8. PMID: 12378443. http://www.ncbi.nlm.nih.gov/pubmed/12378443

Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol. 2000 Jul-Aug;21(4):363-7. PMID: 10865014. http://www.ncbi.nlm.nih.gov/pubmed/10865014

Case Study

Lilly LS. Treatment of acute and recurrent idiopathic pericarditis. Circulation. 2013 Apr 23;127(16):1723-6. https://doi.org/10.1161/CIRCULATIONAHA.111.066365. PMID: 23609551. http://www.ncbi.nlm.nih.gov/pubmed/23609551**

Spodick DH. Acute pericarditis: classic electrocardiogram. Am J Geriatr Cardiol. 2003 Jul-Aug;12(4):266. PMID: 12888710. http://www.ncbi.nlm.nih.gov/pubmed/12888710

Editorial/Comment

Mascitelli L, Pezzetta F. Electrocardiography in acute pericarditis. Cleve Clin J Med. 2006 Aug;73(8):705. PMID: 16917996. http://www.ncbi.nlm.nih.gov/pubmed/16917996

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