Signs and symptoms:
- Presence of 2 of the 4 following features confirms acute pericarditis: typical chest pain, pericardial rub on exam, typical ECG changes, pericardial effusion.
- Typically, sudden-onset sharp chest pain localized to the retrosternal or left precordial region with radiation to the back, trapezius ridge, neck, or epigastrium. It is frequently aggravated by inspiration, movement, swallowing, or lying supine, with pain relief or improvement on sitting up or leaning forward. Pain often is absent in slowly developing tuberculous, postirradiation, and neoplastic or uremic pericarditis.
- Fever
- Dyspnea/orthopnea
- Fatigue/weakness
- Near syncope
Physical Exam 
- Pericardial friction rub: Highly specific for acute pericarditis:
- High-pitched scratching or creaking sound pathognomonic of acute pericarditis
- Best heard at left sternal border, with patient leaning forward, using stethoscope diaphragm
- Rub has 1–3 components per cardiac cycle (ventricular systole, atrial systole, early ventricular filling), 3 components is typical (56% of patients with sinus rhythm)
- Can be confused with systolic murmurs of mitral or tricuspid regurgitation
- Correlates poorly with presence and size of pericardial effusion. Rub may be heard even if large pericardial effusion is present
- Pericardial effusion, in the extreme, cardiac tamponade (see separate topic on cardiac tamponade). Tamponade on presentation increases the likelihood of underlying neoplastic disease
- EKG features:
- Abnormal in
90% of cases of acute pericarditis:
- Stage 1: Diffuse concave-upward ST-segment elevation involving multiple coronary artery territories with associated PR-segment depression (80%), and absence of pathologic Q-waves or reciprocal ST-segment depression
- Stage 2: ST-junction returns to baseline accompanied by T-wave flattening
- Stage 3: Diffuse T-wave inversion observed during recovery period
- Stage 4: Return of T-waves to normal
- Other EKG clues of acute pericarditis or large pericardial effusion:
- Low QRS voltage
- Electrical alternans (<10% in acute pericarditis) is regular alteration in the amplitude or configuration of EKG complexes that can be seen with large effusions.
- Atrial arrhythmias or atrial premature beats
DIAGNOSTIC TESTS & INTERPRETATION
Lab
- Elevated ESR: This may be the only laboratory test needed.
- Moderate granulocytosis or lymphocytosis
- Moderate elevations of creatine phosphokinase (CK), creatine phosphokinase MB isoform (CK-MB), or cardiac troponin T or troponin I may occur and reflect accompanying myopericarditis.
- Subsequent laboratory studies to define the etiology of pericarditis may include: Tuberculin skin test, blood cultures, viral cultures, blood urea nitrogen, creatinine, HIV test, viral cultures, thyroid studies, antinuclear antibody titer, rheumatoid factor, cold agglutinins, and fungal serologies
Imaging
- Not routinely useful in uncomplicated acute pericarditis
- CXR may show enlargement of the cardiac silhouette with occasional "water-bottle" configuration seen with moderate/large effusions.
- CXR or chest CT may demonstrate underlying cause (malignancy) or associated pleural effusion (usually left-sided).
- CT/MRI may confirm pericardial effusion or pericardial thickening and exclude aortic dissection.
- Echo:
- Absence of pericardial effusion does not exclude acute pericarditis.
- Can be useful for detecting, localizing, and estimating size of pericardial effusion and guiding pericardiocentesis
- Pericardial fluid is seen as echo-free space surrounding heart chambers.
- May demonstrate right atrial/RV diastolic collapse or exaggerated inspiratory tricuspid/pulmonic flow with reciprocal mitral flow suggesting cardiac tamponade.
- Pericardiocentesis and pericardial biopsy:
- In patients with cardiac tamponade (see topic on cardiac tamponade) or to exclude suspected purulent pericarditis
DIFFERENTIAL DIAGNOSIS
- Acute MI:
- EKG in pericarditis is more likely than MI to show the following:
- ST segments concave, elevation <5 mm
- ST segment elevation more diffuse, does not reflect specific myocardial perfusion territories
- Reciprocal changes are absent
- Myocarditis
- Early repolarization
Outline
If an underlying cause such as bacterial infection or cancer can be identified, treatment should focus on that cause. The suggestions below pertain to the most common, idiopathic form of acute pericarditis.
ADDITIONAL TREATMENT
General Measures
- Rest, avoidance of vigorous activity, and use of NSAIDs are mainstays.
- No mode of therapy can reliably prevent complications such as tamponade or constriction.
- Bed rest until chest pain and fever have diminished; frequent observation with vital sign monitoring and repeat echo if a moderate-large effusion is present.
- Avoidance of anticoagulation is recommended to decrease risk of cardiac tamponade.
- If anticoagulation is mandatory (mechanical heart valves), IV heparin preferred over oral anticoagulation.
- Uncomplicated pericarditis can be management on outpatient bases as long as close follow-up is guaranteed.
- Hospitalization recommended in patients with the high-risk features listed below:
- Rule out acute MI, if ECG unclear or cardiac enzymes elevated.
- Need to rule out purulent effusion by pericardiocentesis
- Large pericardial effusion
- Exam findings suggesting cardiac tamponade
- Parenteral analgesia for relief of refractory chest pain
- Ongoing anticoagulant therapy
SURGERY
- Pericardiocentesis:
- Increased jugular venous pressure, tachycardia, hypotension, and pulsus paradoxus signal cardiac tamponade and need for emergent pericardiocentesis
- IV fluids and inotropic drugs may temporarily provide hemodynamic support prior to pericardiocentesis to exclude purulent, tuberculous, or neoplastic pericarditis
- Surgical subxiphoid pericardiotomy (pericardial window) or transthoracic endoscopic pericardiotomy:
- Limited palliative procedure for patients with poor prognosis
- Operative mortality = 10%.
- Procedure of choice for patients with expected long-term survival or loculated pericardial effusions
- Percutaneous balloon pericardiotomy:
- Palliative option for large pericardial effusions/tamponade
- Echo- or fluoroscopic-guided insertion of dilating balloon into pericardial sac, creating tear in pericardium
Outline
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