Pericarditis

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Introduction

Pericarditis is an inflammation of the pericardium - the outer, fibrous, parietal pericardium and an inner serous pericardium. The pericardial space normally has 50 ml pericardial plasma ultrafiltrate, though this frequently increases with pericarditis.

Pericarditis has many causes, including infection, inflammatory conditions, and metabolic disorders, but usually a cause cannot be found. It can cause chest pain or tightness, with symptoms worse with deep breathing. Diagnosis is made on symptoms, a friction rub, and findings on ECG, chest X-ray, or echocardiogram. Treatment is related to cause, though NSAIDs are frequently used for pain and control of inflammation.

 

Pericardium has a number of functions.

 

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.

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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, gram-negatives, Hemophilus in children
  • Tuberculosis
  • fungi: Histoplasma, Blastomyces, Coccidiodes, Aspergillus, Candida
  • parasites: toxoplasma, amebiasis, echinococcosis

immune/inflammatory

  • rheumatoid arthritis
  • SLE
  • scleroderma
  • sarcoidosis
  • mixed connective tissue disease
  • inflammatory bowel disease
  • amyloidosis

 

other

  • renal failure/uremia 
  • hypothyroidism
  • post-MI, CABG
  • trauma
  • malignancy (commonly metastases)
  • radiation

 

medications

  • hydralazine, isoniazid, phenytoin, procainamide

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Pathophysiology

Acute pericarditis is 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.

 

The pericardium has is innervated by sympathetic and somatic receptors, including stretch. This are likely responsible for transmitting pain.

 

Acute pericarditis develops quickly, while chronic disease is present for over 6 months.

 

Pericardial effusion is a collection of fluid. This can be serous, serosanguinous, blood, pus, or chyle.

 

Cardiac tamponade occurs following a large effusion, in which cardiac filling and cardiac output drop. A rapidly developing effusion can cause tamponade, as the pericardium cannot quickly stretch. However, a slow effusion can grow to over 1L without causing tamponade.

 

Constrictive pericarditis is a rare finding. It occurs with marked inflammation and fibrosis of the pericardium, leading to impaired ventricular filling and stroke volume.

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Signs and Symptoms

  • history
  • physical exam

History

Patiends can present with symptoms of inflammation or of fluid accumulation.

 

Acute pericarditis can cause:

  • chest  pain, often rapid onset, relieved by sitting forward, worse by sitting down
  • shortness of breath
  • 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 paradoxus - inspiration increases RV pressure, pushing the septum leftward and dropping CO.

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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
  • PR depression
  • effusion can reveal decreased QRS voltage, electrical alternans

Echocardiography

  • perform urgently if tamponade is suspected

CT/MRI may also be done

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Differential Diagnosis

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Treatments

Assess and treat the patient's ABC's. This commonly includes:

Other treatments to consider include:

 

Other treatments to consider, pending clinical situation, include:

Colchicine may be used to prevent recurrent pericarditis

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Consequences and Course

Pericarditis usually resolves in 70% of cases; worse outcomes are seen with bacterial, tuberculous, or malignant causes. Complications can include:

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Resources and References

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Topic Development

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