Clinical Notes : Cardiovascular Disease

113. Acute Pericarditis

Acute Pericarditis

 

Definitions

Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial ECG changes. 

Anatomy and pathophysiology

The pericardium normally contains as much as 20-50 mL of an ultrafiltrate of plasma.

Approximately 90-120 mL of additional pericardial fluid can accumulate rapidly in the pericardium without an increase in pressure. The capacity of the atria and ventricles to fill is mechanically compromised with further fluid accumulation, which can result in marked increases in pericardial pressure, eliciting reduced stroke volume, decreased cardiac output, and hypotension (cardiac tamponade physiology).

The rapidity of fluid accumulation influences the hemodynamic effect.

With slow accumulation of fluid, the pericardium has time to stretch and accomodate the fluid increase so that hemodynamic compromise does not ensue.

Drainage of the pericardium occurs via the thoracic duct and the right lymphatic duct into the right pleural space.

Pericardial physiology includes 3 main functions.

  • First, through its mechanical function, the pericardium promotes cardiac efficiency by limiting acute cardiac dilation, maintaining ventricular compliance with preservation of the Starling curve, and distributing hydrostatic forces.

    • The pericardium also creates a closed chamber with subatmospheric pressure that aids atrial filling and lowers transmural cardiac pressures.

  • Second, through its membranous function, the pericardium shields the heart by reducing external friction and acting as a barrier against extension of infection and malignancy.

  • Third, through its ligamentous function, the pericardium anatomically fixes the heart.

 
 

Etiology

  • Acute Pericarditis

    • Serous Pericarditis

      • usually caused by noninfectious inflammation :

        • rheumatoid arthritis (RA)

        • systemic lupus erythematosus (SLE)

        • hypothyroidism

        • drugs

          • penicillin, cyclosporin, cromolyn sodium, procainamide, hydralazine, methyldopa, isoniazid, mesalazine, reserpine, phenytoin, and minoxidil

    • ​​Fibrous and serofibrinous pericarditis (the most frequent type of pericarditis) 

      • Common causes include :​

        • viral (most common)

          • ​coxsackievirus B, [9] echovirus, adenoviruses, influenza A and B viruses, enterovirus, mumps virus, Epstein-Barr virus, human immunodeficiency virus (HIV), herpes simplex virus (HSV) type 1, varicella-zoster virus (VZV), measles virus, parainfluenza virus (PIV) type 2, and respiratory syncytial virus (RSV), cytomegalovirus (CMV), and hepatitis viruses A, B, and C (HAV, HBV, HCV, respectively).

        • uremia

        • radiation

        • trauma

        • cardiac surgery​

        • postinfarction (including Dressler syndrome)

        • acute myocardial infarction (MI)

    • ​Purulent or suppurative pericarditis
      • causative organisms may arise from :

        • direct extension

        • hematogenous seeding

        • lymphatic extension

        • direct introduction during cardiotomy

      • causative organisms include :

        • common

          • gram-positive species such as Streptococcus pneumoniae and other Streptococcus species and Staphylococcus. [11] Isolated gram-negative species include Proteus, Escherichia coli, Pseudomonas, Klebsiella, Salmonella, Shigella, Neisseria meningitidis, and Haemophilus influenzae

        • less common

          • Legionella, Nocardia, Actinobacillus, Rickettsia, Borrelia burgdorferi (Lyme borreliosis), Listeria, Leptospira, Chlamydophila psittaci, and Treponema pallidum (syphilis)

        • anaerobes

          • up to 40% of pediatric cases

      • Immunosuppression facilitates this condition

    • ​Hemorrhagic pericarditis

      • most commonly caused by :

        • tuberculosis

        • direct neoplastic invasion

      • can also occur in

        • severe bacterial infections

        • patients with a bleeding diathesis

        • after cardiac surgery

        • trauma

  • Chronic Pericarditis

    • Adhesive Mediastinopericarditis

      • usually follows

        • suppurative pericarditis

        • caseous pericarditis

        • cardiac surgery

        • irradiation

    • Constrictive pericarditis

      • usually caused by

        • suppurative pericarditis

        • caseous pericarditis

        • hemorrhagic pericarditis

  • Cardiac Tamponade

    • malignant tamponade

      • Caused by 

        • tumours

    • traumatic tamponade​

      • Caused by 

        • injury to the thorax or upper abdomen

    • iatrogenic

      • Caused by 

        • central line placement

        • pacemaker insertion

        • cardiac catheterization

        • sternal bone marrow biopsies

        • pericardiocentesis

 
 
 
 

Epidemiology

  • Incidence of pericarditis :

    • 1% of emergency room visits in patients with ST-segment elevation

    • 1 per 1000 hospital admissions

    • 10% of patients with advanced renal failure before dialysis

  • Incidence of pericardial effusion :

    • malignant disease is the most commen cause

    • uremia accounts for 20% of cases

  • Acute pericarditis is more common in men than in women.

    • However, although more common in adults than in children, adolescents are more commonly affected than young adults. 

Presentation

  • Palpitations may be the presenting complaint

  • Chest pain is the cardinal symptom of pericarditis

    • 85-90% of cases

    • usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm.

    • usually pleuritic, nature ranges from sharp, dull, aching, burning, or pressing

    • intensity varies from barely perceptible to severe

    • worse during inspiration, when lying flat, or during swallowing and with body motion

    • may be relieved by leaning forward while seated

  • Common associated signs and symptoms include

    • low-grade intermittent fever

    • dyspnea/tachypnea (a frequent complaint and may be severe with myocarditis, pericarditis, and tamponade)

    • cough

    • dysphagia

    • symptoms of URTI

  • Children may present with abdominal pain

  • Cardiac tamponade

    • most feared complication

    • pericardial effusion severe enough to cause serious obstruction to the inflow of blood to the heart

    • Beck's triad of signs

      • distended neck veins

      • muffled heart sounds

      • low blood pressure

Diagnosis

  • For acute pericarditis to formally be diagnosed, two or more of the following criteria must be present:

    • chest pain consistent with a diagnosis of acute pericarditis (sharp chest pain worsened by breathing in or a cough)

    • pericardial friction rub

    • pericardial effusion

    • changes on electrocardiogram (ECG) consistent with acute pericarditis

  • Clinical history

    • high index of suspicion in presence of conditions included in pericarditis etiology

    • especially recent viral infection

    • the classic feature of chest pain and dyspnea with pericarditis may be subtle and can be confused with other diagnoses, particularly in elderly individuals.

    • be careful not to confuse pericarditis with esophageal disorders, costochondritis, or other causes of noncardiac chest pain.

  • Physical examination

    • auscultaion

      • pericardial rub

    • signs of systemic disease known to be associated with periarditis

  • Urinalysis

    • looking for CKD

  • ECG

    • looking for typical stage 1-4 features of pericarditis

      • stage 1 -- diffuse, positive, ST elevations with reciprocal ST depression in aVR and V1. Elevation of PR segment in aVR and depression of PR in other leads especially left heart V5, V6 leads indicates atrial injury.

      • stage 2 -- normalization of ST and PR deviations

      • stage 3 -- diffuse T wave inversions (may not be present in all patients)

      • stage 4 -- EKG becomes normal OR T waves may be indefinitely inverted

    • ​The two most common clinical conditions where ECG findings may mimic pericarditis are

      • acute myocardial infarction (AMI)

      • generalized early repolarization

 

Management :

Refer all cases to A+E for further investigation and management

  • In the absence of poor prognostic predictors, aspirin and NSAIDs with gastroprotection is first line treatment in uncomplicated acute pericarditis, and may be prescribed on an outpatient basis

    • Avoid NSAIDs and corticosteroids in acute MI pericarditis because they may interfere with ventricular healing, remodeling, or both

  • Poor prognostic predictors :

    • fever of more than 100.4°F (38°C)

    • subacute onset

    • immunosuppression

    • trauma

    • oral anticoagulation therapy

    • aspirin or nonsteroidal anti-inflammatory drug (NSAID) treatment failure

    • myopericarditis

    • severe pericardial effusion

    • cardiac tamponade

 
BMJ Best Practice.png

Doctor NS, Shah AB, Coplan N, Kronzon I.

Acute pericarditis.

Prog Cardiovasc Dis. 2017 Jan - Feb;59(4):349-359

View/Access

Imazio M, Gaita F, LeWinter M.

Evaluation and treatment of pericarditis: a systematic review.

JAMA. 201

View/Access

Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, et al.

Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology.

Eur Heart J. 2004 Apr. 25(7):587-610.

View/Access

Hooper AJ, Celenza A.

A descriptive analysis of patients with an emergency department diagnosis of acute pericarditis.

Emerg Med J. 2013 Dec. 30 (12):1003-8.

View/Access

Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, et al.

Day-hospital treatment of acute pericarditis: a management program for outpatient therapy.

J Am Coll Cardiol. 2004 Mar 17. 43(6):1042-6

View/Access

Brady WJ, Perron AD, Martin ML, Beagle C, Aufderheide TP.

Cause of ST segment abnormality in ED chest pain patients.

Am J Emerg Med. 2001 Jan. 19(1):25-8.

View/Access

 

Pericarditis

BMJ Best Practice

February 2019

View/Access

2015 ESC Guidelines for the diagnosis and management of pericardial diseases

European Society of Cardiology

Am J Emerg Med. 2001 Jan. 19(1):25-8.

View/Access

 

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