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Information ⬇

Author(s): David Sprigings and John B. Chambers

  • Consider acute pericarditis in any patient with pleuritic central chest pain (pericarditis accounts for 5% of patients with acute severe chest pain).
  • The typical patient is an otherwise healthy young man with a presumed viral aetiology (male:female ratio 2:1).
  • Other causes are given in Table 53.1.
  • There is a recurrence rate of 30% by 18 months.

Priorities ⬆ ⬇

  1. Review the observations and make a focused clinical assessment (Table 53.2). A pericardial friction rub is heard in less than one-third of cases so its absence does not exclude the diagnosis. If there are clinical signs of cardiac tamponade, arrange urgent echocardiography (see Chapter 54 for further management).
  2. Obtain an ECG and other investigations (Table 53.3). The diagnosis of acute pericarditis is based on the clinical features supported by the ECG. The distinction between acute pericarditis, acute coronary syndrome with ST elevation and non-specific chest pain with benign early repolarization can sometimes be difficult: see Table 7.4. A pericardial effusion is common but not invariable in acute pericarditis.
  3. Confirmation of the diagnosis of acute pericarditis requires at least two of the following four features:
    • Pericarditic chest pain: central chest pain worse on inspiration and eased by sitting forward
    • Pericardial friction rub
    • New widespread ST segment elevation or PR depression on ECG
    • Pericardial effusion (new or worsening)
  4. Relieve pain: an NSAID is usually sufficient (Table 53.4). Severe pain may require morphine.
  5. Review the clinical findings and investigation results. Decide on the likely aetiology. Are there any high-risk features?
    • Ill patient
    • Fever >38oC
    • Sub-acute course
    • Large pericardial effusion (>20 mm thickness on echocardiography)
    • Clinical or echocardiographic features of cardiac tamponade (Chapter 54)
    • Immunosuppression
    • Evidence of myopericarditis
    • Pericarditis in the setting of chest trauma
    • Oral anticoagulant therapy

Further Management ⬆ ⬇

  1. Admit or discharge?

    Admit if there are high-risk features or a specific non-viral cause of pericarditis is suspected.

    Low-risk patients with presumed viral pericarditis can be managed as outpatients.

  2. Are there signs of severe sepsis?

    Consider purulent pericarditis. This is rare, and is usually due to spread of intrathoracic infection, for example following thoracic trauma or complicating bacterial pneumonia.

    Start antibiotic therapy with advice from a microbiologist (e.g. IV vancomycin and ceftriaxone) after taking blood cultures.

    Perform pericardiocentesis if there is an effusion large enough to be drained safely (thickness >20 mm), and send fluid for Gram stain and culture.

    Consider tuberculous or fungal infection if the effusion is purulent but no organisms are seen on Gram stain.

    Discuss further management with a cardiologist or cardiothoracic surgeon.

  3. Possible Dressler (postpericardiotomy) syndrome

    Consider Dressler syndrome if the patient has had recent cardiac surgery (typically 2–4 weeks previously). It is an acute self-limiting illness, with fever, pericarditis and pleuritis.

    Investigations show:

    • ECG: typical changes of acute pericarditis or only non-specific ST/T abnormalities.
    • Chest X-ray: an enlarged cardiac silhouette (due to pericardial effusion), bilateral pleural effusions and transient pulmonary infiltrates.
    • ESR: this is typically around 100 mm/h.

    If the pain has not settled after 48h of treatment with NSAID, consider colchicine (Table 53.4).

  4. Presumed viral (‘idiopathic’) acute pericarditis

    This is the likely diagnosis in young and otherwise healthy adults. It may be preceded by a flu-like illness and is usually a self-limiting disorder lasting 1–3 weeks.

    Give an NSAID with gastroprotection, continued for 1 week after the pain resolves. Colchicine should be co-administered, and continued for 3 months, to reduce the risk of recurrence (Table 53.4).

    Patients should be advised to avoid exercise until there is no evidence of active disease (normal inflammatory markers).

  5. When are corticosteroids indicated?

    Prednisolone should be given in place of NSAIDs when:

    • Acute pericarditis complicates autoimmune disease, provided there are no features to suggest bacterial infection
    • NSAID are contraindicated in viral pericarditis

Further Reading ⬆

Imazio M, Gaita F, LeWinter M (2015) Evaluation and treatment of pericarditis: a systematic review JAMA 314, 1498–1506.

The Task Force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) (2015) 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. http://www.escardio.org/static_file/Escardio/Guidelines/Publications/PERICA/2015%20Percardial%20Web%20Addenda-ehv318.pdf