Pericarditis, Emergency Medicine

Basics

Description

Inflammation, infection, or infiltration of the pericardial sac surrounding the heart:
- Pericardial effusion may or may not be present.
Acute pericarditis:
- Rapid in onset
- Potentially complicated by cardiac tamponade from effusion
Constrictive pericarditis:
- Results from chronic inflammation causing thickening and adherence of the pericardium to the heart

Etiology

Idiopathic (most common)
Viral:
- Echovirus
- Coxsackie
- Adenovirus
- Varicella
- Epstein " Barr virus
- Cytomegalovirus
- Hepatitis B
- Mumps
- HIV
Bacterial:
- Tuberculosis
- Staphylococcus
- Streptococcus
- Haemophilus
- Salmonella
- Legionella
Fungal:
- Candida
- Aspergillus
- Histoplasmosis
- Coccidioidomycosis
- Blastomycosis
- Nocardia
Parasitic:
- Amebiasis
- Toxoplasmosis
- Echinococcosis
Neoplastic:
- Lung
- Breast
- Lymphoma
Uremia
Myocardial infarction:
- Dressler syndrome
Connective tissue disease:
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Scleroderma
Radiation
Chest trauma
Postpericardiotomy
Aortic dissection
Myxedema
Pancreatitis
Inflammatory bowel disease
Amyloidosis
Drugs:
- Procainamide
- Cromolyn sodium
- Hydralazine
- Dantrolene
- Isoniazid
- Penicillins
- Doxorubicin/daunorubicin

Diagnosis

Signs and Symptoms

Chest pain
Fever
Mild dyspnea
Cough
Hoarseness
Nausea
Anorexia

History

Chest pain:
- Pain radiating to the ridge of the trapezius from phrenic irritation
- Central or substernal pain
- Sudden onset
- Sharp
- Pleuritic
- Worse when supine or with cough
- Improved with leaning or sitting forward
Previous episodes of pericarditis
History of fever or infection
History of malignancy or autoimmune disease

Physical Exam

Tachypnea
Tachycardia
Odynophagia
Friction rub:
- Heard best at lower left sternal border
- Very specific
- Triphasic rub is classic
- Can have any of these 3 components:
  - Presystolic
  - Systolic
  - Early diastolic
- Intermittent and exacerbated by leaning forward
Beck triad with the accumulation of pericardial fluid:
- Muffled heart sounds
- Increased venous pressure (distended neck veins)
- Decreased systemic arterial pressure (hypotension)
Ewart sign:
- Dullness and bronchial breathing between the tip of the left scapula and the vertebral column
Pulsus paradoxus:
- Exaggerated decrease (>10 mm Hg) in systolic pressure with inspiration
Constrictive pericarditis:
- Signs of both right- and left-sided heart failure
- Pulmonary and peripheral edema
- Ascites
- Hepatic congestion

Essential Workup

ECG has 4 classic stages
Stage 1:
- Concave ST-elevations diffusely except aVR and V1
- PR segment depressions with elevation in aVR
Stage 2:
- Normalization of ST and PR segments
- T-wave flattening
Stage 3:
- Diffuse T-wave inversions
Stage 4:
- T-waves normalize, may have some persistent T-wave inversions
Atypical changes may include localized ST-elevations or T-wave inversions
Myocardial involvement suggested by intraventricular conduction delay, new bundle branch block, or Q-waves
Pericardial effusion suggested by electrical alternans

Diagnosis Tests & Interpretation

Lab

CBC:
- May show leukocytosis
Erythrocyte sedimentation rate and C-reactive protein:
- May be elevated, can follow for resolution
Cardiac enzymes:
- Helpful in distinguishing pericarditis from myocardial infarction
- May also be elevated in myopericarditis

Imaging

CXR:
- Most often normal
- May show enlargement of the cardiac silhouette or calcification of pericardium
- No change in heart size until >250 mL of fluid has accumulated in the pericardial sac
Echocardiography:
- Diagnostic method of choice for the detection of pericardial fluid
- Can detect as little as 15 mL of fluid in the pericardial sac
- Bedside US good screening tool
Chest CT:
- Useful for the detection of calcifications or thickening of the pericardium
- Can help rule out other etiologies

Diagnostic Procedures/Surgery
Pericardiocentesis:

Pericardial fluid can help determine underlying etiology.
Fluid sent for protein, glucose, culture, cytology, Gram and acid-fast stains, and fungal smears

Differential Diagnosis

Acute myocardial infarction
Pulmonary embolism
Pneumothorax
Aortic dissection
Pneumonia
Empyema
Cholecystitis
Pancreatitis

Treatment

Pre-Hospital

ABCs, IV access, O2, monitor
Consider fluid bolus if no crackles.

Initial Stabilization/Therapy

ABCs
Emergent pericardiocentesis:
- For hemodynamic compromise secondary to cardiac tamponade
- Removal of a small amount of fluid can lead to a dramatic improvement.
- US guidance if available

Ed Treatment/Procedures

Treatment dependent on the underlying etiology
Idiopathic, viral, rheumatologic, and post-traumatic:
- NSAID regimens effective
- Corticosteroids reserved for refractory cases
Bacterial:
- Aggressive treatment with IV antibiotics along with drainage of the pericardial space
- Search for primary focus of infection.
- Therapy guided by determination of pathogen from pericardial fluid tests
Neoplastic:
- Treat underlying malignancy.
Uremic:
- Intensive 2 " 6 wk course of dialysis
- Caution should be used if using nonsteroidal medications.
Expected course/prognosis:
- Most patients will respond to treatment within 2 wk.
- Most have complete resolution of symptoms.
Few progress to recurrent episodes with eventual development of constrictive pericarditis or cardiac tamponade.

Medication

Ibuprofen 300 " 800 mg q6 " 8h for days to weeks depending on severity:
- Can also be tapered to prevent recurrence
- Improves coronary blood flow
- GI prophylaxis with 20 mg omeprazole
Aspirin 800 mg PO q6 " 8h 7 " 10 days:
- Taper off over 3 " 4 wk
- Omeprazole as with ibuprofen
- Colchicine 1 " 2 mg 1 day, then 0.5 " 1 mg daily 3 mo
Colchicine alone: 1 " 2 mg 1 day, then 0.5 " 1 mg daily 3 mo:
- Combination with aspirin decreased recurrence rate
- Lower doses may also be effective.
Indomethacin 25 " 50 mg q6h:
- May restrict coronary blood flow
Prednisone 0.2 " 0.5 mg/kg daily 2 " 4 wk with taper:
- Used for refractory cases
- For use if aspirin/NSAIDs contraindicated
- Associated with increased rate of recurrence
- Also beneficial in uremic and autoimmune pericarditis

NSAIDs and aspirin are not teratogenic in 1st 20 wk of pregnancy
Glucocorticoids may be used during pregnancy.
Avoid aspirin and high-dose steroids when breast-feeding.
Colchicine is generally contraindicated except with familial Mediterranean fever.

Follow-Up

Disposition

Admission Criteria

ICU:
- Hemodynamic instability
- Cardiac tamponade
- Malignant dysrhythmia
- Status postpericardiocentesis
Telemetry unit:
- Suspicion of myocardial infarction
- Severe pain
- Suspicion of bacterial etiology
- Any high-risk criteria
High-risk criteria:
- Large effusion (>2 cm total)
- Anticoagulant use
- Malignancy
- Temperature >38 °C
- Traumatic pericarditis
- Immunosuppression
- Pulsus paradoxus
- Slow onset

Discharge Criteria

Mild symptoms in patients without any hemodynamic compromise
Close follow-up
Able to tolerate a regimen of oral medication
Debate on need for ECG to evaluate for effusion prior to discharge

Issues for Referral
Follow-up with cardiology:

Recurrent cases
Admitted patients

Followup Recommendations

Follow up with primary care physician for re-evaluation and verification of resolution of symptoms and absence of complications in 1 " 2 wk.

Pearls and Pitfalls

Classic history: Viral illness preceding development of sharp, positional chest pain
Rub is very specific but not always audible.
The challenge is distinguishing pericarditis from acute MI and other etiologies of chest pain.
Mainstay of therapy is NSAIDs.

Additional Reading

Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart Fail Rev. 2013;18(3):355 " 360.
Maisch B, Seferovi PM, Risti AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25:587 " 610.
Sheth S, Wang DD, Kasapis C. Current and emerging strategies for the treatment of acute pericarditis: A systematic review. J Inflamm Res. 2010;3:135 " 142
Spodick DH. Acute pericarditis: Current concepts and practice. JAMA. 2003;289:1150 " 1153.
Spodick DH. Risk prediction in pericarditis: Who to keep in hospital? Heart. 2008;94:398 " 399.

Codes

ICD9

420.90 Acute pericarditis, unspecified
420.91 Acute idiopathic pericarditis
423.2 Constrictive pericarditis
420.0 Acute pericarditis in diseases classified elsewhere
017.90 Tuberculosis of other specified organs, unspecified
039.8 Actinomycotic infection of other specified sites
074.21 Coxsackie pericarditis
115.93 Histoplasmosis, unspecified, pericarditis
420.99 Other acute pericarditis

ICD10

I30.0 Acute nonspecific idiopathic pericarditis
I30.9 Acute pericarditis, unspecified
I31.1 Chronic constrictive pericarditis
I30.1 Infective pericarditis
A18.84 Tuberculosis of heart
A39.53 Meningococcal pericarditis
B33.23 Viral pericarditis
B39.9 Histoplasmosis, unspecified

SNOMED

15555002 Acute pericarditis (disorder)
85598007 Constrictive pericarditis (disorder)
266235007 Acute idiopathic pericarditis
70189005 Viral pericarditis (disorder)
187059008 Histoplasmosis with pericarditis (disorder)
27806003 Coxsackie pericarditis
67256000 Tuberculosis of pericardium (disorder)

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