Pericarditis

Acute Pericarditis: A summary of the 2015 European Society of Cardiology Guidelines For The Diagnosis And Management Of Pericardial Diseases ( Full Text )

Diagnosis:

Two or more of the following…
  • Chest pain consistent with pericarditis (sharp, worse with laying flat and inspiration, better sitting up),  80-90%
  • Pericardial friction rub (high pitched, scratchy , left sternal border),  <33%
  • Typical ECG changes , 60%
  • Pericardial effusion , 60%

ECG findings:

  • ST elevation in multiple leads
  • PR depression (not diagnostic of pericarditis, can occur in MI)
  • Absence of reciprocal ST depression (exception V1 and aVR may show ST depression and PR elevation)
  • Progression over days is classically taught as:
    • ST elevation with PR depression
    • Normalization of ST and PR segments
    • Inversion of T waves
    • Normalization of all segments

Testing:  

Geared at determining the cause of pericarditis as well as confirmation of diagnosis.
  • ECG
  • CBC with diff
  • High sensitivity CRP
  • ESR
  • Troponin – elevated in 15-25%, at higher risk of CHF or arrhythmia.
  • Creatinine
  • LFTs
  • Chest X-ray
  • Echocardiogram to r/o large effusion

Causes: 

  • Viruses (most common)
  • Bacterial Infection
  • Fungal Infections
  • Trauma
  • Subacute MI
  • Tuberculosis
  • HIV/AIDS
  • Renal Failure
  • Radiation Therapy
  • Lupus
  • Rheumatoid Arthritis
  • Malignancy
  • Medications: Phenytoin, Warfarin, Heparin, Procainamide

Treatment:

NSAIDs + Colchicine is most effective.
  • NSAIDs + PPI (1st time or recurrence)
    • Ibuprofen 600 mg every 8 hours x 1-2 weeks, then decrees by 200-400 mg every 2 weeks
    • Aspirin 750-100 mg every 8 hours x 1-2 weeks, then decrease by 250-500 mg every 2 weeks (utilized in Europe)
  • Colchicine (in addition to NSAIDS) decreases duration and likelihood of recurrence if taken for 3 months*
    • 0.5 mg BID if weight >70kg
    • 0.5 mg Daily if weight <70kg
  • Steroids not recommended as first line agent. Only use if NSAIDs contraindicated. Low dose prednisone 0.2–0.5 mg/kg/day or equivalent is recommended. *
*Note: Guidelines recommend continued treatment until CRP is normalizing, then initiating taper.

Disposition: 

  • Good prognosis, may be discharged with at least 1 week follow up:
    • Afebrile
    • Not immunocompromised
    • No hx of trauma
    • No evidence of myocarditis
    • No large pericardial effusion
    • Not anticoagulated
  • Poor prognosis, admission recommended if at least one major criterion present:
    • Fever
    • Subacute course- no clear sudden onset
    • Large Effusion (diastolic free space >20mm on echo)
    • Cardiac Tamponade
    • No response to NSAIDS within 7 days
    • Immunosuppressed (minor)
    • Anticoagulated (minor)
    • Trauma (minor)
    • Myocarditis (minor)

Source: https://academic.oup.com/view-large/figure/108776039/ehv31801.tif

Prognosis: 

“Most patients with acute pericarditis (generally those with presumed viral or idiopathic pericarditis) have a good long-term prognosis.Cardiac tamponade rarely occurs in patients with acute idiopathic pericarditis, and is more common in patients with a specific underlying aetiology such as malignancy, TB or purulent pericarditis. Constrictive pericarditis may occur in <1% of patients with acute idiopathic pericarditis, and is also more common in patients with a specific aetiology. The risk of developing constriction can be classified as low (<1%) for idiopathic and presumed viral pericarditis; intermediate (2–5%) for autoimmune, immune-mediated and neoplastic aetiologies; and high (20–30%) for bacterial aetiologies, especially with TB and purulent pericarditis.36 Approximately 15–30% of patients with idiopathic acute pericarditis who are not treated with colchicine will develop either recurrent or incessant disease, while colchicine may halve the recurrence rate.”

Notes:

  • Other definitions:
    • Incessant Pericarditis: Symptoms for > 4-6 weeks but < 3months without remission
    • Recurrent Pericarditis: Symptom free 4-6 weeks before recurrence.
    • Chronic: Symptoms lasting > 3months

References:

  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-64. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29.

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