Pericarditis

Causes: Common

• Idiopathic (Most common cause)
• Viral Infection (esp. Coxsackievirus)
• Myocardial Infarction
• Medication Causes of Pericarditis
• Acquired Immunodeficiency Syndrome (AIDS)

Causes of pericarditis and pericardial effusions
Cause	Prevalence	Investigation
Idiopathic	Most common	Diagnosis of exclusion
Viral	Most common cause of infectious pericardial disease Adenovirus Coxsackievirus (Most common viral cause) Cytomegalovirus (CMV) Epstein-Barr Virus (Mononucleosis) Influenza Human Immunodeficiency Virus (occurs in 20% of AIDS Cases) Mumps/Measles/ Varicella Viral Hepatitis	Not routine to perform serological testing. Diagnosis is mainly based on history and examination. Do not forget human immunodeficiency virus in high-risk patients
Bacterial	Uncommon Staphylococcus aureus (high mortality): Empyema with direct spread or hematogenous spread in children Streptococcus Pneumoniae Haemop hilusInfluenzae Mycobacterium tuberculosis (mortality approaches 85% for untreated cases) – Most common cause in developing countries Salmonella Meningococcus Syphilis Whipple Disease Rickettsia	Blood cultures and pericardial fluid cultures to identify organisms and direct treatment
Tuberculosis	Uncommon – consider patient demographic and exposure status	Chest X-ray, tuberculin testing, Quantiferon Gold, sputum cultures
Fungal and parasitic	Rare in Australia
Autoimmune	Uncommon Systemic Lupus Erythematosus /Rheumatoid Arthritis/Ankylosing SpondylitisSarcoidosis / Scleroderma Rheumatic Fever Inflammatory Bowel Disease Wegener’s Granulomatosis Familial mediterranean fever	Target testing to likely underlying disease
Neoplastic	15% of cancer patient Metastatic: Breast Cancer (most common), Lung Cancer (most common), Leukemia, Lymphoma, Malignant Melanoma Primary: Sarcoma, Mesothelioma Cancer treatment complications	Pericardial fluid cytology and pericardial biopsy
Post-procedural	Common after cardiac or thoracic surgery	History
Post-myocardial infarction	Acute Myocardial Infarction (in first 2-4 days following event) Post-MI Syndrome (Dressler’s Syndrome, occurs in weeks to months following event)
Uraemic	Suspect in patients with chronic renal impairment, especially peri-dialysis periods	Urea and creatinine
Radiation	Consider in patients undergoing chest irradiation
Drugs	Rare
Chest Trauma

Other: Uremia, Gout, Pregnancy, Medications(Dantrolene,Isoniazid,Penicillin, Phenytoin,Rifampin)

History 

• sharp, retrosternal pains (98.3% of cases)
• radiate to neck or arm
• Aggravation of the pain with deep inspiration and supine positioning are hallmark feature

Physical examination

• cardiovascular examination
• Blood pressure should be measured in both arms 
• vital signs
• frictional rub 
• pulsus paradoxus
• elevated jugular venous pressure (JVP)
• changes in heart or lung sounds
• peripheral oedema.
• signs of shock (ie diaphoresis, clamminess, tachycardia, decreased blood pressure

ECG

• PR segment depression
• ST segment elevation
  • not localised to a coronary vascular territory 
  • absence of reciprocal ST segment depression

Features suggesting Benign Early Repolarisation (BER)	Features suggesting pericarditis
ECG changes usually stable over time (i.e non-progressive) ST elevation limited to the precordial leads Absence of PR depression Prominent T waves Characteristic “fish-hook” appearance in V4 (Notched J-point elevation)	Generalised ST elevation Presence of PR depression Normal T wave amplitude Absence of “fish hook” appearance in V4 Dynamic ECG changes that evolve slowly over time
ST segment / T wave ratio < 0.25 ST segment height = 1 mm T wave height = 6 mmST / T wave ratio = 0.16 The ST / T wave ratio < 0.25 is consistent with BER.	ST segment / T wave ratio > 0.25 ST segment height = 2 mm T wave height = 4 mm ST / T wave ratio = 0.5 The ST / T wave ratio > 0.25 is consistent with pericarditis.

Xray

• chest X-ray may appear normal despite the patient having small or moderate-sized effusions 
• A predominantly ‘globular‑shaped’ cardiac silhouette with an increased cardiothoracic ratio >0.5 is a feature of large pericardial effusion
• DDx: cardiomyopathy. 

Bloods:

• Cardiac Trops: usually negative. However, an elevated cardiac-specific troponin level may occur in pericarditis, as inflammation of the epicardium without involvement of myocardium can still elevate cardiac-specific troponin levels in approximately 30% of cases.

Complications

• Pericardial Effusion (60% of cases)
  • Serous effusion: Viral Pericarditis
  • Exudative effusion: Neoplastic, Tuberculosis and Bacterial Pericarditis
• Cardiac Tamponade
  • Uncommon in Viral Pericarditis or idiopathic Pericarditis (5-15%)
  • Occurs in 60% of exudative cases
• Constrictive Pericarditis

 Treatment for acute pericarditis

• should be targeted as much as possible to the underlying etiology
• goals of therapy are the relief of pain and resolution of inflammation (and, if present, pericardial effusion)
• Activity restriction
  • strenuous physical activity may trigger recurrence of symptoms; therefore, such activity should be avoided until symptom resolution. 
  • Athletes should not participate in competitive sports until there is no longer evidence of active disease (eg, resolution of symptoms)
• Nonsteroidal anti-inflammatory drugs
  • NSAID regimens
    • Ibuprofen — 400 to 800 mg of ibuprofen three times daily (pericarditis associated with an acute myocardial infarction, aspirin is preferred, and the use of an NSAID other than aspirin should be AVOIDED, since anti-inflammatory therapy may impair scar formation)
    • Aspirin — Aspirin can be given at a dose of 750 to 1000 mg every six to eight hours followed by gradual tapering every week for a treatment period of three to four weeks
    • Indomethacin — Indomethacin can be administered at a dose of 50 mg three times daily for one to two weeks followed by slow tapering.
  • Gastrointestinal protection
    • History of peptic ulcer disease
    • Age greater than 65 years
    • Concurrent use of aspirin , corticosteroids, or anticoagulants
  • Colchicine
    • reduces symptoms, decreases the rate of recurrent pericarditis, and is generally well tolerated
• Glucocorticoids
  • Used when refractory to NSAIDs and colchicine , and a specific cause for the pericarditis has been excluded
• Interventional therapeutic techniques
  • Pericardial drainage
  • Pericardiotomy