acute%20pericarditis
ACUTE PERICARDITIS

Pericarditis is the inflammation of the pericardial sac and accounts for 5% of visits to the emergency room for chest pain without myocardial infarction.

The patient experiences chest pain that is sharp, pleuritic and improves with sitting up and leaning forward.

Acute pericarditis is characterized by new-onset pericarditis with at least 2 of the following:

  • Pericarditic chest pain
  • Pericardial friction rubs
  • New or worsening pericardial effusion
  • ECG finding of a new diffuse ST-segment elevation or PR depression

Classification

Acute Pericarditis

  • New-onset pericarditis with at least 2 of the following criteria:
    • Pericarditic chest pain
    • Pericardial friction rubs
    • New or worsening pericardial effusion
    • ECG finding of a new diffuse ST-segment elevation or PR depression
  • Additional supportive findings include elevated serum markers of inflammation and presence of pericardial inflammation from an imaging study (CT, CMR)

Recurrent Pericarditis

  • Occurs in 15-30% of patients after the documented initial episode of acute pericarditis and a symptom-free interval of ≥4-6 weeks
  • Usually presents within 18 months of the initial acute episode with similar findings and criteria for diagnosis

Incessant Pericarditis

  • Symptoms persisting for >4-6 weeks but <3 months with no clear-cut remission following the acute episode

Chronic Pericarditis

  • Disease process that lasts for >3 months

Evaluation

  • Initial evaluation should include screening for risk factors that would affect management plan
  • High-risk features for hospitalization (at least 1 of the following):
    • Fever >38°C
    • Subacute onset of symptoms (attributable to TB, uremia, neoplasm or collagen vascular disorders) developing over days or weeks
    • Large pericardial effusion
    • Cardiac tamponade
    • No response within 7 days to Aspirin or NSAIDs
    • Hypotension
    • Jugular venous distention
    • Trauma
    • Myopericarditis
    • Patients who are on anticoagulant therapy or are immunocompromised
  • Any clinical presentation that is suggestive of an underlying cause (eg bacterial, neoplastic or systemic inflammatory diseases) necessitates an etiology search and should also consider an epidemiological background check (ie TB prevalence)
    • An obligatory etiology workup is not required in all patients with acute pericarditis, particularly in areas with low TB prevalence, because the common causes of pericarditis are associated with a benign course and diagnostic studies reveal a low yield
    • Diagnostic work-up for suspected neoplastic or bacterial pericarditis may include surgical drainage or pericardiocentesis and percutaneous or surgical pericardial biopsy
    • Further testing is directed to specific etiologies according to clinical presentation

History

  • History taking should include the characteristics of the pain, patient’s medical history (ie history of cardiovascular, autoimmune or connective tissue diseases), smoking history and family history of cardiac diseases

Physical Examination

  • During physical exam, assess patient for changes in vital signs (eg tachycardia, decreased BP), elevated jugular venous pressure, pulsus paradoxus, presence of distant heart or abnormal lung sounds, peripheral edema

Laboratory Tests

  • It is recommended that the following work-up be done in all patients with suspected pericarditis:
    • Routine blood tests and serum markers of inflammation [eg C-reactive protein (CRP), ESR, WBC count] and myocardial injury (eg troponin, creatine kinase)
    • Thyroid, renal and liver function tests

Imaging

  • Chest X-ray
  • Electrocardiogram (ECG)
  • Transthoracic echocardiography
  • Second-level investigative pericarditis work-up includes CT and/or cardiac magnetic resonance (CMR)

Differential Diagnosis

Alternative Diagnosis 

  • Conditions that present with chest pain need to be ruled out: Acute coronary syndromes, aortic dissection, myocardial ischemia or infarction, pneumonia, pulmonary embolism, pneumothorax, gastroesophageal reflux disease, gastric ulcer, tuberculosis, musculoskeletal disorders, herpes zoster and panic disorder
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