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  • Module
    Video Lectures
    Review Articles
    Practice Questions
    Flashcards
    Internal Medicine
    261
    270
    1620
    1624
    Pediatrics
    164
    116
    997
    640
    Surgery
    128
    58
    866
    420
    OB/GYN
    102
    65
    616
    422
    Psychiatry
    64
    51
    307
    300

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  • 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

    Etiological classifications

    Cause

    Notes

    Infectious

    Viral

    Including Coxsackievirus, echovirus, adenovirus


    Bacterial

    Tuberculosis

    Non-infectious

    Idiopathic

    Most common in clinical practice


    Trauma

    Blunt or penetrating chest trauma


    Uremic

    Seen in patients with renal failure


    Malignancy

    Primary or secondary tumors of the pericardium

    Autoimmune

    Post-cardiac injury / Post-Myocardial infarction

    Post-pericardiotomy, Post-traumatic • Dressler’s syndrome (2–6 weeks post-MI) • Postinfarction fibrinous pericarditis (1–3 days post MI)


    Rheumatological disorders

    Lupus, rheumatoid arthritis


    Drug induced

    Procainamide, hydralazine, phenytoin

    NOTE: Most common cause of infectious pericarditis is Coxsackievirus.


    Clinical FeaturesTable 2: Symptoms and signs of acute pericarditis

    Features

    Description

    Chest pain

    Sharp, pleuritic, positional (better when sitting up and leaning forward)

    Pericardial friction rub

    Scratchy sound heard over the heart on auscultation, best at the left sternal border

    Dyspnea

    Shortness of breath due to pain or effusion

    Fever, cough, palpitations, fatigue

    Nonspecific symptoms


    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

    Laboratory studies

    Etiology

    Elevated BUN, creatinine, potassium

    Uremic pericarditis

    Blood cultures (2 sets)

    Bacterial pericarditis

    ANA, rheumatoid factor

    Autoimmune pericarditis

    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

    Treatment

    Indication

    Notes

    NSAIDs

    First-line for pain and inflammation

    Commonly used drugs include ibuprofen, naproxen, indomethacin.

    Colchicine

    Prevent recurrence

    Given for three months, and often combined with NSAIDs

    Corticosteroids

    Severe/refractory cases

    Prednisone, taper dose gradually

    Pericardiocentesis

    Large effusion or tamponade

    Diagnostic and therapeutic intervention

    Antibiotics

    Bacterial pericarditis

    Tailored based on causative organism

    Hemodialysis

    Uremic pericarditis

    Associated with chronic kidney disease

    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

    Complication

    Features

    Management

    Cardiac tamponade

    Beck’s triad • Hypotension • Jugular venous distension • Muffled heart sounds

    Emergency pericardiocentesis

    Recurrent pericarditis

    Similar symptoms of initial episode

    Long-term colchicine, monitor regularly

    Chronic constrictive pericarditis

    Signs of right heart failure, Kussmaul’s sign

    Surgical pericardiectomy

    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.

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