Skip to Main Content

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

  • Suspected myocarditis or cardiac tamponade

  • Hemodynamic instability

  • Failure to respond within a few days to ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.