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JukkaLehtonen
JyriLommi

Pericarditis

Essentials

  • Pericarditis is a common cause of chest pain in patients presenting out of office hours.
  • Hospitalisation is usually indicated in the presence of
    • fever
    • low blood pressure and high heart rate
    • elevated venous pressure
    • a large pericardial effusion
    • immunosuppression.
  • Most cases of pericarditis may be managed at home.
  • Echocardiography will assist diagnosis and management planning.
  • First-line pharmaceutical treatment usually consists of an NSAID and colchicine.
  • Frequent recurrences of acute pericarditis are possible, in which case the management usually involves colchicine for six months.

Aetiology

  • Infection (viral, bacterial or fungal)
  • Active connective tissue disorder (rheumatoid arthritis, SLE, systemic scleroderma)
  • Malignancy (usually associated with metastasis)
  • Severe renal failure (uraemia)
  • Pericardial injury
    • Post-myocardial infarction (Dressler's syndrome)
    • Post-pericardiotomy
    • Cardiac trauma
  • Following a cardiac procedure
    • Angioplasty
    • Insertion of a pacemaker
    • Ablation therapy for arrhythmia
  • Drug reaction (certain antimicrobials, cytotoxic drugs)
  • Sequela of radiotherapy targeting the chest and cardiac region
  • Idiopathic (the most common cause)

Signs and symptoms

  • Chest pain is the most common symptom of acute pericarditis.
  • The pain is sharp and stabbing and does not usually radiate.
  • A pericardial friction rub can be heard in the early phase and is usually position dependent.
    • The friction rub is usually biphasic, systolic-diastolic, often only audible during the inspiratory phase of respiration and may sound similar to rubbing sandpaper together.
    • The rub may be absent in the presence of a large pericardial effusion.
  • Filled jugular veins, increased jugular venous pressure
  • Symptoms associated with an infection

Investigations

  • Chest x-ray
    • Often normal
    • The heart silhouette may appear enlarged if pericardial effusion is large.
    • Changes in the lung parenchyma are possible in infections.
  • ECG
    • Phasically alteringST-T changes resulting from myocarditis
    • Low-voltage if a large accumulation of pericardial fluid is present
    • Tachycardia
  • Laboratory tests
    • CRP elevated in > 80% of patients
    • Mild or moderate leukocytosis, elevated SR
    • The concentration of troponin (TnT, Tnl) increases if pericarditis is accompanied by myocarditis (myopericarditis).
  • Echocardiography http://www.dynamed.com/condition/pericardial-effusion-and-tamponade#ECHOCARDIOGRAPHY
    • The key investigation
    • Pericardial effusion
      • An abnormal finding is defined as a fluid depth > 5 mm during a diastole.
      • A moderate effusion is defined as a fluid depth of 10-20 mm.
      • A large effusion is defined as a fluid depth > 20 mm.

Differential diagnosis

  • Myocardial infarction must be borne in mind as a possible alternative diagnosis.
    • The severe pain of pericarditis may resemble that of myocardial infarction.
    • However, the ECG changes are more diffuse and disproportionate to the clinical symptoms.
      • ST changes are seen in several leads.
      • T wave changes are common.
    • A patient with pericarditis usually presents with generalised symptoms of an infection.

Treatment

Acute pericarditis

Medication Colchicine for Pericarditis

  1. An NSAID http://www.dynamed.com/condition/acute-and-recurrent-pericarditis#NONSTEROIDAL_ANTIINFLAMMATORY_DRUGS__NSAIDS_ and colchicine
    • NSAID
      • Alternatives
      • Whilst symptoms persist and until the CRP has returned to normal which usually takes 7-14 days. This is followed by gradual tapering of the dose as symptoms allow.
  2. Prednisone 0.2-0.5 mg/kg http://www.dynamed.com/condition/acute-and-recurrent-pericarditis#CORTICOSTEROIDS
    • Is started only if the NSAID and colchicine do not provide therapeutic response.
    • Should be avoided as it predisposes to recurring pericarditis, particularly at higher doses.
    • Not a first-line drug, used mainly in treatment-resistant cases
    • The drug is a justified choice, if the patient has a systemic inflammatory condition (for example SLE) and for pregnant patients.
    • Symptoms improve rapidly
    • In long-term treatment with glucocorticoids, blood sugar levels should be monitored and prevention of osteoporosis should be implemented.
    • Tapering of long-term medication must be carried out very slowly.

Recurrent pericarditis Colchicine for Pericarditis

  1. An NSAID and colchicine
    • An NSAID for 2-4 weeks followed by gradual tapering of the dose as symptoms allow
    • Colchicine for 6 months followed by gradual tapering of the dose if symptoms allow
      • 0.5 mg twice daily when weight is > 70 kg
      • 0.5 mg once daily when weight is ≤ 70 kg or the patient has renal failure (GFR 30-60; calculator Gfr Calculator)
  2. Prednisone 0.2-0.5 mg/kg
    • Increases the risk of recurrence.
    • The tapering of the prednisone medication is often problematic.
    • Should a combination of an NSAID + colchicine prove to be inefficient, glucocorticoid therapy may justifiably be considered; prednisone for 2-4 weeks followed by gradual tapering of the dose.

Prognosis

    References

    • Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J 2013;34(16):1186-97. [PubMed]
    • Lilly LS. Treatment of acute and recurrent idiopathic pericarditis. Circulation 2013;127(16):1723-6. [PubMed]
    • Adler Y, Charron P, Imazio M et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36(42):2921-64. [PubMed]