Pericarditis

Why do we care?

Approximately 5% of emergency department visits for chest pain in North America and Western Europe are due to pericarditis. Recurrence rates are reported to be 20-30% in idiopathic cases. 50% of those who experience one recurrence will have more episodes.2


Definitions:

TYPE

Duration

Acute

Symptoms lasting < 4-6 weeks

Incessant

Symptoms for > 4-6 weeks but < 3 months without remission

Recurrent

Symptom free 4-6 weeks before recurrence

Chronic

Symptoms lasting > 3months


Diagnosis:

Two or more of the following criteria are required for the diagnosis1

Symptom

Frequency

Notes

Chest pain

80-90%

Sharp, worse with laying flat and inspiration, better sitting up

Pericardial friction rub

< 33%

High pitched, scratchy , left sternal border

Typical ECG changes

60%

See section below

Pericardial effusion

60%


ECG findings:

  • ST elevation in multiple leads
  • PR depression 
  • Absence of reciprocal ST depression (exception V1 and aVR may show ST depression and PR elevation)
  • Progression over days is classically taught as:
    • ST elevation with PR depression
    • Normalization of ST and PR segments
    • Inversion of T waves
    • Normalization of all segments
ST elevation and PR depression seen in II, III, aVF, V2-V5
aVR shows ST depression and PR elevation

Testing:  

Geared at determining the cause of pericarditis as well as confirmation of the diagnosis.

  • ECG
  • CBC with diff
  • High sensitivity c-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)
  • Troponin – elevated in 15-25%, at higher risk of CHF or arrhythmia.
  • Creatinine
  • Liver function tests (LFTs)
  • Chest X-ray
  • Echocardiogram to rule out large effusion

Causes:

Cases are labeled idiopathic when no specific cause can be determined. However, it is believed that most of these are caused by viruses.

  • Viral Infection
  • Bacterial Infection
  • Fungal Infections
  • Trauma
  • Subacute MI
  • Tuberculosis
  • HIV/AIDS
  • Renal Failure
  • Radiation Therapy
  • Lupus
  • Rheumatoid Arthritis
  • Malignancy
  • Medications: Phenytoin, Warfarin, Heparin, Procainamide

Treatment:

The combination of NSAIDs and Colchicine is most effective. Provide GI prophylaxis (PPI therapy) with NSAIDs.

Medication

Initial Dose

Taper

Notes

Ibuprofen

600 mg every 8 hours x 1-2 weeks

Decrees by 200-400 mg every 2 weeks

Provide GI prophylaxis (PPI therapy)

Aspirin

750-100 mg every 8 hours x 1-2 weeks

Decrease by 250-500 mg every 2 weeks

  • Preferred in patients with CAD

  • Provide GI prophylaxis (PPI therapy)

Colchicine

  • 0.5 mg BID if weight >70kg

  • 0.5 mg Daily if weight <70kg

  • Continue until CRP normalizes

  • Consider taper, half dose in the last weeks (not required)

In addition to NSAIDS. Decreases duration and likelihood of recurrence (by 50%) if taken for 3 months

Prednisone

0.2–0.5 mg/kg/day

Continue until CRP normalizes, then taper

Not recommended as first line agent. Only use if NSAIDs contraindicated

In pregnancy1

  • Aspirin is the anti-inflammatory of choice in the first and second trimesters as it has been used safely in pregnant women with anti-phospholipid syndrome. Typically withdrawn after 20 weeks gestation. 
  • Prednisone can also be used during pregnancy and breastfeeding. 

Disposition: 

  • Good prognosis, may be discharged with at least 1 week follow up:
    • Afebrile
    • Not immunocompromised
    • No hx of trauma
    • No evidence of myocarditis
    • No large pericardial effusion
    • Not anti-coagulated
  • Poor prognosis. The European guidelines recommend admission and search for causes if at least one major or minor criterion is present. “Major criteria are validated by multivariate analysis, minor criteria area are baed on expert opinion and literature review.”1
    • Major
      • Fever (38C / 100.4 F)
      • Subacute course- no clear sudden onset
      • Large pericardial effusion (diastolic free space >20mm on echo)
      • Cardiac Tamponade
      • No response to NSAIDS within 7 days
    • Minor
      • Immunosuppressed
      • Anti-coagulated
      • Trauma
      • Myocarditis

Prognosis:

  • Long term prognosis is generally good.2 
  • Cardiac tamponade is rare in idiopathic or viral cases. More likely to occur in cases of malignancy or infective cases.1
  • Constrictive pericarditis occurs in < 1% in idiopathic or viral cases, 2-5% of autoimmune and malignant cases, 20-30% of infective causes.1
  • Recurrence rates without colchicine therapy are reported as 15-30% for idiopathic pericarditis. Treatment with colchicine reduces this rate by 50%.1
  • Avoidance of athletics and sports is recommended for a minimum of 3 months. This is increased to 6 months if myocardial involvement is present. 2
  • Long term prognosis with myocardial involvement is still good, with 90% having normal LV function and no increased risk of death at 12 months.1

Further Reading

Myocarditis And Pericarditis In The Pediatric Patient: Validated Management Strategies Date Release: Jul 2015 Reviews signs and symptoms of myocarditis and pericarditis in children, diagnostic tests, and treatment strategies for both conditions.

Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department Date Release: Jan 2021 When a patient presents to the ED with symptoms of STEMI, emergency clinicians must be prepared to initiate coordinated, time-sensitive, and effective diagnostic and treatment strategies, with the ultimate goal of initiation of reperfusion.

Emergency Department Management of Non–ST-Segment Elevation Myocardial Infarction Date Release: Jan 2020 When patients present to the ED with suspected myocardial infarction, it is critical to differentiate NSTEMI from other cardiac causes and initiate swift, evidence-based management. Review the latest evidence on diagnosis and treatment of NSTEMI.


References:

  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-64. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29. Full Text
  2. Chiabrando J, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis. J Am Coll Cardiol. 2020 Jan, 75 (1) 76–92.https://doi.org/10.1016/j.jacc.2019.11.021

Leave a Reply

Your email address will not be published.