Pericarditis

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Pericarditis
Classification and external resources
PericarditisECG.JPG
An ECG showing pericarditis. Note the ST elevation in multiple leads with slight reciprocal ST depression in aVR.
ICD-10 I01.0, I09.2, I30I32
ICD-9 420.0, 420.90, 420.91, 420.99, 423.1, 423.2
DiseasesDB 9820
MedlinePlus 000182
eMedicine med/1781 emerg/412
MeSH D010493

Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart). A characteristic chest pain is often present.

The causes of pericarditis are varied, including infections of the pericardium by viruses or bacteria (e.g., Mycobacterium tuberculosis), idiopathic causes, uremic pericarditis, post-infarct pericarditis (within 24 hours of a heart attack), or Dressler's syndrome (weeks to months after a heart attack).

Classification[edit]

Pericarditis can be classified according to the composition of the fluid that accumulates around the heart.[1]

Types of pericarditis include the following:

Acute vs. chronic[edit]

Depending on the time of presentation and duration, pericarditis is divided into "acute" and "chronic" forms. Acute pericarditis is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or even as a result of a heart attack (myocardial infarction). Chronic pericarditis however is less common, a form of which is constrictive pericarditis. The following is the clinical classification of acute vs. chronic:

  • Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)

Signs and symptoms[edit]

Figure A shows the location of the heart and a normal heart and pericardium (the sac surrounding the heart). The inset image is an enlarged cross-section of the pericardium that shows its two layers of tissue and the fluid between the layers.
Figure B shows the heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.[2]

Substernal or left precordial pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in), is the characteristic pain of pericarditis.[3] The pain may resemble the pain of angina pectoris or heart attack, but differs in that pain changes with body position, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Acute myocardial infarction (heart attack) can also cause pericarditis, but the presenting symptoms often differ enough to warrant diagnosis. The following table organizes the clinical presentation of pericarditis:[3]

Characteristic/Parameter Pericarditis Myocardial infarction
Pain description Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion Does not change the pain Can increase the pain
Position Pain is worse in the supine position or upon inspiration (breathing in) Not positional
Onset/duration Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER

Physical examinations[edit]

The classic sign of pericarditis is a friction rub heard with a stethoscope on the cardiovascular examination usually on the lower left sternal border.[3] Other physical signs include a patient in distress, positional chest pain, diaphoresis (excessive sweating), and possibility of heart failure in form of precardial tamponade causing pulsus paradoxus, and the Beck's triad of low blood pressure (due to decreased cardiac output), distant (muffled) heart sounds, and distension of the jugular vein (JVD).

Acute complications[edit]

Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in patients who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration),low blood pressure (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid.

In such cases of cardiac tamponade, EKG or Holter monitor will then depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively.

The diagnostic test for cardiac tamponade, is trans-esophageal echocardiography (TEE) although trans-thoracic echocardiography (TTE) can also be utilized in cases where there is a high suspicion of aortic dissection and high blood pressure, or in patients where esophageal probing is not feasible. Chest X-ray can depict a "water bottle" appearance of the heart in tamponade, although chest X-ray is neither specific enough nor accurate enough in the acute setting.[citation needed] Of note is the fact that chest x-ray can be entirely normal in acute pericardial effusion/tamponade and therefore should not be relied upon as the sole diagnostic tool.[citation needed]

Causes[edit]

Infectious[edit]

Pericarditis may be caused by viral, bacterial, or fungal infection. The most common viral pathogen has traditionally been considered to be coxsackievirus based on studies in children from the 1960s, but recent data suggest that adults are most commonly affected with cytomegalovirus, herpesvirus, and HIV.[4][5] Pneumococcus or tuberculous pericarditis are the most common bacterial forms. Anaerobic bacteria can also be a rare cause.[6] Fungal pericarditis is usually due to histoplasmosis, or in immunocompromised hosts Aspergillus, Candida, and Coccidioides.[citation needed] The most common cause of pericarditis worldwide is infectious pericarditis with Tuberculosis.[citation needed]

Other[edit]

Diagnosis[edit]

An ECG showing pericarditis.

Laboratory tests[edit]

This diagram depicts the elevation of respective cardiac markers in a myocardial infarction (heart attack). Although this diagram is only for heart attack, elevated values of these markers might be seen in pericarditis.

Laboratory values can show increased urea (BUN), or increased blood creatinine in cases of uremic pericarditis. Generally however, laboratory values are normal, but if there is a concurrent myocardial infarction (heart attack) or great stress to the heart, laboratory values may show increased cardiac markers like Troponin (I, T), CK-MB, Myoglobin, and LDH1 (Lactase Dehydrogenase isotype 1). The preferred initial diagnostic testing is the EKG which will show a 12-lead electrocardiogram with diffuse, non-specific, concave, ST segment-elevations all leads except aVR and V1[3] and PR segment-depression possible in any lead except aVR;[3] sinus tachycardia, and low-voltage QRS complexes can also be seen if there is subsymptomatic levels of pericardial effusion. The PR depression is often seen early in the process as the thin atria are affected more easily than the ventricles by the inflammatory process of the pericardium.

Since the mid-19th Century, retrospective diagnosis of pericarditis has been made upon the finding of adhesions of the pericardium.[7] When pericarditis is diagnosed clinically, the underlying cause is often never known; it may be discovered in only 16-22 percent of patients with acute pericarditis.[citation needed]

Imaging[edit]

Treatment[edit]

The treatment in viral or idiopathic pericarditis is with aspirin,[3] or non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen).[8] Colchicine may be added to the above[8] as it decreases the risk of further episodes of pericarditis.[9]

Severe cases may require one or more of the following:

  • pericardiocentesis to treat pericardial effusion/tamponade
  • antibiotics to treat tuberculosis or other bacterial causes.
  • steroids are used in acute pericarditis but are not favored because they increase the chance of recurrent pericarditis.
  • in rare cases, surgery
  • in cases of constrictive pericarditis, pericardiectomy

References[edit]

  1. ^ images
  2. ^ "Pericarditis". nhlbi.nih.gov. Retrieved 5 August 2014. 
  3. ^ a b c d e f American College of Physicians (ACP). "Pericardial disease". Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. p. 64. ISBN 9781934465288. 
  4. ^ AU Corey GR; Campbell PT; Van Trigt P; Kenney RT; O'Connor CM; Sheikh KH; Kisslo JA; Wall TC (August 1993). "Etiology of large pericardial effusions". American Journal of Medicine 95 (2): 209–13. doi:10.1016/0002-9343(93)90262-N. PMID 8356985. 
  5. ^ Campbell PT; Li JS; Wall TC; O'Connor CM; Van Trigt P; Kenney RT; Melhus O; Corey GR (April 1995). "Cytomegalovirus pericarditis: a case series and review of the literature". American Journal of Medical Science 309 (4): 229–34. doi:10.1097/00000441-199504000-00009. PMID 7900747. 
  6. ^ Brook I. Pericarditis caused by anaerobic bacteria.Int J Antimicrob Agents 2009; 297–300.
  7. ^ Austin Flint (1862). "Lectures on the diagnosis of diseases of the heart: Lecture VIII". American Medical Times: Being a weekly series of the New York Journal of Medicine 5 (July to December): 309–311. 
  8. ^ a b Tingle, LE; Molina, D; Calvert, CW (Nov 15, 2007). "Acute pericarditis.". American family physician 76 (10): 1509–14. PMID 18052017. 
  9. ^ Alabed, S; Cabello, JB; Irving, GJ; Qintar, M; Burls, A (Aug 28, 2014). "Colchicine for pericarditis.". The Cochrane database of systematic reviews 8: CD010652. doi:10.1002/14651858.CD010652.pub2. PMID 25164988. 

General References

External links[edit]