Overview

Pericarditis is the inflammation of the pericardium, which can be acute, subacute, or chronic. It commonly presents with sharp, pleuritic chest pain that improves when sitting up and leaning forward. The most common cause is idiopathic. Diagnosis is based on clinical findings, including pleuritic chest pain, a pericardial friction rub on auscultation, diffuse ST elevation and PR segment depression on ECG, and evidence of pericardial effusion on echocardiography. Management of pericarditis involves treating the underlying cause, reducing inflammation (with NSAIDs as the first line), and monitoring for complications.

Buzzwords Scenario: A patient presents with sharp, pleuritic chest pain that improves when sitting up and leaning forward. Examination reveals a pericardial friction rub, and ECG shows diffuse ST elevation.

Definition

Pericarditis is the inflammation of the pericardium, the double-walled sac surrounding the heart. Classified into acute, subacute, and chronic:

• Acute pericarditis: < 6 weeks

• Subacute pericarditis: 6 weeks to 6 months

• Chronic pericarditis: > 6 months

  
  

NOTE: Acute pericarditis is recognized as the most common pathological process involving the pericardium.

EtiologyTable 1: Etiologies of acute pericarditis

NOTE: Most common cause of infectious pericarditis is Coxsackievirus.

Clinical FeaturesTable 2: Symptoms and signs of acute pericarditis

Diagnosis

Suspect pericarditis when a patient presents with pleuritic chest pain, tachypnea, and dyspnea.Pericarditis has 4 principle diagnostic features:

• Chest pain: Severe, retrosternal, pleuritic in nature, intensified by lying supine and relieved by sitting up and leaning forward

• Pericardial friction rub on auscultation. Found in about 85% of patients at some point of the disease

• Characteristic ECG changes (Image 1): Diffuse ST elevations. ST depression in aVR and V1. PR segment depression

• Pericardial effusion is initially diagnosed with echocardiography. For confirmation, CT and MRI (gold standard for confirmation) can be used

Figure 1. ECG changes in pericarditis.

Heilman, J. (2016, May 27). Wikimedia Commons: https://commons.wikimedia.org/wiki/File:PericarditisMyocarditis.jpg

Supportive laboratory studies

• Elevated cardiac biomarkers (troponin, CK-MB)

• Leukocytosis on CBC

Table 3: Other laboratory studies for more specific Etiologies

ALERT: Do not forget to rule out all differentials of acute chest pain (e.g., myocardial infarction, myocarditis)

Management

Treat the underlying cause, reduce inflammation, and monitor for complications (Table 3)

Table 3: Management of pericarditis

ALERT: Don’t forget to use gastroprotective drugs (e.g., omeprazole) when administering NSAIDs.

NOTE: In patients with renal or hepatic dysfunction, the use of colchicine is contraindicated.

Complications

Table 4: Complications of pericarditis

NOTE: Do not forget to do echocardiography when pericarditis is suspected to rule out life threatening cardiac tamponade.

Prognosis

The majority of patients with acute pericarditis can be managed as outpatients with careful follow-up. However, hospitalization is advisable under certain conditions:

Suspected specific causes

• Tuberculosis

• Neoplastic disease

• Bacterial infection

Predictors of poor prognosis:

• Fever >38°C

• Subacute onset

• Large pericardial effusion

Reference

Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, & Jameson J (Eds.). (2022). Harrison’s Principles of Internal Medicine, 21st ed. (pp 2022-2023). McGraw-Hill Education.