Pericarditis, Acute

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Central chest pain aggravated by coughing, inspiration, or recumbency

• Pericardial friction rub on auscultation

• Characteristic ECG changes

GENERAL CONSIDERATIONS

• Acute pericarditis is an inflammatory condition of the pericardium

• Causes include viral, tuberculosis, other bacterial, immune-mediated, uremia, neoplastic, post–myocardial infarction, post–cardiac surgery, trauma, and idiopathic

• Pericarditis should also be considered in the setting of persistent fevers with a pericardial effusion or unexplained new cardiomegaly on chest x-ray

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Chest pain (sharp, anteriorly located, and pleuritic in nature)

  • – Pain intensity may decrease by sitting upright and forward, and it may radiate to 1 or both trapezius ridges

  • – Sometimes the chest pain is dull in nature with variable location and intensity

• Many have prodromal symptoms suggestive of a viral infection

PHYSICAL EXAM FINDINGS

• Fever and tachycardia

• Pericardial friction rub:

  • – Typically scratchy

  • – Consisting of 1 to 3 components (corresponding to ventricular systole, early diastole, and atrial contraction)

  • – Localized or widespread, but most commonly at the left sternal border

  • – May be postural and better detected in the seated upright position or during suspended respiration

DIFFERENTIAL DIAGNOSIS

• Acute myocardial infarction

• Aortic dissection

• Pulmonary embolus

• Pneumothorax

• Pneumonia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• CBC with differential count

• Elevated C-reactive protein

• Cardiac troponin to evaluate for contaminant myocarditis

• Antinuclear antibody titer

• Tuberculin skin test

• Additional diagnostic lab tests tailored to the clinical presentation

ELECTROCARDIOGRAPHY

• Four stages of ECG changes:

  • – Stage I: Widespread, concave upward ST-segment elevation with reciprocal ST depressions in AVR and V1; PR depression in leads other than AVR; PR elevation in AVR

  • – Stage II: Normalization of the ST and PR segments several days later

  • – Stage III: Isoelectric or depressed ST segments with inverted T waves—these changes may never occur or may persist indefinitely

  • – Stage IV: Normalization of the T waves, which may occur weeks or months later

• Sustained arrhythmias are uncommon and may suggest concomitant myocarditis or other cardiac disease

IMAGING STUDIES

• Chest x-ray:

  • – Often normal unless associated with a pericardial effusion of at least 200 mL, in which case the cardiac silhouette may be enlarged

• Echocardiography:

  • – Often normal unless associated with a pericardial effusion

DIAGNOSTIC PROCEDURES

• Pericardial biopsy in selected cases

TREATMENT

CARDIOLOGY REFERRAL

• Suspected myocarditis

• If pericardiocentesis is being considered

• Recurrent or chronic pericarditis

• Arrhythmias

HOSPITALIZATION CRITERIA

• High fever (> 100.4°F or 38°C) and leukocytosis

• Immunosuppressed state

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