ACUTE

PERICARDITIS

Emily O. Jenkins M.D.

AM Report
7.13.09

Incidence

Exact incidence and prevalence are

unknown
Diagnosed in 0.1% of hospitalized
patients and 5% of patients admitted for
non-acute MI chest pain
Observational study: 27.7 cases/100,000
population/year

Etiology: Can be Tricky. . .

Standard diagnostic evaluations are

oftentimes relatively low yield
One series elucidated a cause in only
16% of patients
Leading possibilities:

Neoplasia
Tuberculosis
Non-tuberculous infection
Rheumatic disease

Initial clinical and echocardiographic

evaluation of patients with suspected
acute pericarditis

Diagnostic Criteria

Chest pain: anterior chest, sudden onset,

pleuritic; may decrease in intensity when leans
forward, may radiate to one or both trapezius
ridges
Pericardial friction rub: most specific, heard best
at LSB
EKG changes: new widespread ST elevation or PR
depression
Pericardial effusion: absence of does not exclude
diagnosis of pericarditis
Supporting signs/symptoms:

Elevated ESR, CRP

Fever
leukocytosis

EKG

Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment

elevations seen best here in
leads II, III, aVF, and V2 to V6. There is also subtle PR segment deviation (positive in
aVR, negative
in most other leads). ST segment elevation is due to a ventricular current of injury

Pericardial Effusion

Cardiomegaly due to a massive pericardial effusion. At least

200 mL of pericardial fluid must accumulate before the
cardiac silhouette enlarges.

Tests

EKG
CXR
PPD
ANA
HIV
Blood cultures
Urgent echocardiogram if evidence of
pericardial effusion
Not necessary:

Viral studies b/c yield is low and management is not

altered

Treatment

NSAIDs + PPI

Aspirin (2-5 g/day)

Ibuprofen (300-800 mg q6-8H)*
Ketorolac

Theoretical concern that anti-platelet agents promote

development of hemorrhagic pericardial effusion has not
been substantiated

Colchicine (0.5-1 mg/day) : may prevent recurrence

Glucocorticoids (prednisone 1 mg/kg/day): ?
increased rate of complications. Should be
restricted to:

Acute pericarditis due to connective tissue disease

Autoreactive (immune-mediated) pericarditis
Uremic pericarditis

*NSAID of choice unless associated with acute MI, where all non-ASA NSAIDs sh

Prognosis for acute idiopathic

pericarditis

Good long-term prognosis

Cardiac tamponade is rare, but up to
70% in cases with specific etiologies (eg.
Neoplastic, tuberculous, purulent)
Constrictive pericarditis occurs in about
1% of patients
15-30% of patients not treated with
colchicine develop either recurrent or
incessant disease

Recurrent Pericarditis

Exact recurrence rate unknown

Most cases considered to be autoimmune
Risk Factors:

Lack of response to aspirin or other NSAID

Glucocorticoid therapy
Inappropriate pericardiotomy
Creation of a pericardial window

For some patients, symptoms can only

be controlled with steroidal therapy

Autoreactive Pericarditis:
diagnostic criteria

Pericardial fluid revealing >5000/mm3

mononuclear cells or antisarcolemmal antibodies
Inflammation in epicardial/endomyocardial biopsies
by >14 cells/mm2
Exclusion of active viral infection both in pericardial
effusion and endocardial/epicardial biopsies
Exclusion of tuberculosis, borrelia burgdorferi,
chlamydia pneumoniae and other bacterial
infection
Absence of neoplastic infiltration in effusion and
biopsy samples
Exclusion of systemic, metabolic disorders and
uremia

Treatment

Aspirin
NSAIDs
Colchicine: can reduce or eliminate need for glucocorticoids
Glucocorticoids: should be avoided unless required to treat
patients who fail NSAID and colchicine therapy

Other immunosuppression

Many believe that prednisone may perpetuate recurrences

Intrapericardial glucocorticoid therapy: sx improvement and prevention
of recurrence in 90% of patients at 3 months and 84% at one year
Azothoprine (75-100 mg/day)
Cyclophosphamide
Mycophenolate: anecdotal evidence only
Methotrexate: limited data
IVIG: limited data

Pericardiectomy: To avoid poor wound healing, recommended to

be off prednisone for one year. Reserved for the following cases:

If >1 recurrence is accompanied by tamponade

If recurrence is principally manifested by persistent pain despite an
intensive medical trial and evidence of serious glucocorticoid toxicity