Pericarditis
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Introduction
The pericardium contains the outer, fibrous, parietal pericardium and an inner serous pericardium. The pericardial space normally has 50 ml pericardial plasma ultrafiltrate, which drains into the pleural space.
Pericardium has a number of functions.
- anchors heart in place
- barrier to infection and malignancy
- reduces friction
- mechanical restraining effects - heart can only dilate so far
The Case of Rita Torres
Rita Torres is a 46 year-old woman who was recovering from a respiratory infection when she developed sudden-onset chest pain and shortness of breath. Concerned about a heart attack, she went to the emergency department, where the physician performed a history, physical exam, and performed a number of investigations before making a diagnosis of pericarditis.
- What did the physican find on physical exam?
- What did Rita's ECG show?
Causes and Risk Factors
Acute pericarditis may be caused by the following:
idiopathic (80-90%)
infection
- coxackie virus, echovirus, adenovirus, influenza virus, enterovirus, HIV, mumps virus, EBV, HSV1, VZV, measles, parainfluenza, RSV, CMV, hepatitis viruses
- Staphyloccocus, Streptococcus, many others
- Tuberculosis
- fungi: Histoplasma, Blastomyces, Coccidiodes, Aspergillus, Candida
immune/inflammatory
- rheumatoid arthritis
- SLE
- scleroderma
- sarcoidosis
- mixed connective tissue disease
other
- renal failure/uremia
- hypothyroidism
- medication
- post-MI, CABG
- trauma
- malignancy (commonly metastases)
- radiation
Pathophysiology
Acute pericarditis is usually caused by inflammation of the pericardium, demonstrating polymorphonuclear (PMN) leukocytes and pericardial vascularization. Exudates, adhesions, or serous/hemorrhagic effusion may occur. Some conditions may also cause granulomatous pericarditis.
Signs and Symptoms
- history
- physical exam
History
Acute pericarditis can cause:
- chest pain
- often rapid onset
- relieved by sitting forward, worse by sitting down
- SOB
- hiccups
- fever
Physical Exam
Findings of pericarditis can include:
- fever
- tachycardia
- tachypnea
- biphasic or triphasic friction rub (scratching)
- best over left sternal edge
- best when patient is sitting up and leaning forward
evidence of tamponade: hypotension, elevatien systemic venous pressure, muffled heart sounds)
evidence of associated myocarditis
Pulsus paridoxus - inspiration increases RV pressure, pushing the septum leftward and dropping CO.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Findings of pericarditis normally reveal:
- mild leukocytosis
- elevated ESR/CRP
- mild elevation of troponin
Other investigations can include:
- BUN, creatinine
- blood cultures
- TB testing
- RF, ANA, anti-DNA antibody
Diagnostic Imaging
CXR
- usually normal if uncomplicated
- can show large cardiac silhouette
ECG can show:
- diffuse ST elevation
Echocardiography
- perform urgently if tamponade is suspected
CT/MRI may also be done
Differential Diagnosis
- aortic dissection
- gastritis
- acute coronary artery vasospasm
- myocardial infarction
- esophageal rupture
- eptic ulcer disease
- esophageal spasm
- pulmonary embolism
- esophagitis
Treatments
Assess and treat the patient's ABC's. This commonly includes:
- oxygen
- monitoring
- ibuprofen may be used to control pain and inflammation.
Other treatments to consider, pending clinical situation, include:
- pericardiocentesis
- pericardial window
- pericardiectomy
Colchicine may be used to prevent recurrent pericarditis
Consequences and Course
Pericarditis usually resolves in 70% of cases; worse outcomes are seen with bacterial, tuberculous, or malignant causes. Complications can include:
- recurrence
- tamponade (especially if on anticoagulation)
- constrictive percarditis
Resources and References
Topic Development
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