Pericarditis

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Background

Pericarditis compared with normal pericardium

Etiology

Clinical Features

Differential Diagnosis

ST Elevation

Evaluation

Diagnostic Criteria for Acute Pericarditis[2]

  • Need 2 of the following
    • Chest pain (typically sharp and pleuritic, improved by sitting up and leaning forward)
    • Pericardial friction rub
    • New or worsening pericardial effusion
    • Suggestive ECG changes

Work-Up

  • ECG
  • Labs
    • WBC, CMP, ESR, CRP, trop
    • Consider TSH, ANA based on clinical suspicion
  • CXR
  • Bedside Ultrasound to rule out effusion
    • ~2/3 of cases will have pericardial effusion[3]
  • Can consider CT or cardiac MRI if workup non-diagnostic and clinical suspicion persists

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression

Classical Teachings with Caveats Below

  • Must differentiate from STEMI (classical teachings are not specific enough to do that)
  • Classically pericarditis has diffuse ST-elevations
    • However, pericarditis may generate localized ST-elevations
    • Pericarditis should never produce ST-depressions (suggestive of reciprocal changes), except in V1 and aVR
  • Classically pericardidits has concave upwards STE
    • However, STEMI may have concave upwards ST-segment morphology as well
    • Rather, it is STE convex upwards or horizontal that favors STEMI
  • Classically pericardititis has PR-depression in viral pericarditis (or PR-elevation in AVR)
    • Less reliable in post-MI patients and those with baseline ECG abnormalities
    • PR-depression is often early and transient in pericarditis
    • In STEMI, PR-depression is associated with atrial injury, though usually not as marked as in viral pericarditis[4]
    • PR-elevation in aVR may also be present in STEMI and is infrequently seen in constrictive pericarditis

Other Findings

  • Leads II and III
    • STE II > STE III favors pericarditis
    • STE III > STE II very strongly favors STEMI
  • STD not in aVR or V1 (reciprocol changes) suggestive of STEMI
  • May see low voltage/alternans if effusion present
  • If early repolarization confounding interpretation check ST:T ratio
    • If (STE)/(T height) in V6 or I > 0.25, then it is likely pericarditis
  • If predominantly inferior STE, ST-depression in aVL is sensitive for STEMI[5]
  • Spodick's sign, purportedly in ~80% - downsloping TP segment, often best seen in lead II and lateral precordial leads[6]
ST-T ratio.jpg
Spodick's sign

Stages of Progression

Stages of pericarditis
PTa depression
  • Stage I:
    • Global concave up ST elevation in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
    • PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
  • Stage II:
    • "pseudonormalisation," ST to baseline, big T's, PR dep
  • Stage III:
    • T wave flatten then inversion
  • Stage IV:
    • Return to baseline

STEMI vs Pericarditis

Disease STEMI Pericarditis
Pain Costant Varies with motion
Fever No Yes
ST changes focal Diffuse elevation
Reciprocal changes Yes No
Q waves Yes No
Pulmonary edema Sometimes No
Wall motion Abnormal Normal

Management

Initial Treatment

  • NSAIDS or Aspirin (ASA)first line treatment (in absence of contraindications) for viral or idiopathic pericarditis.[7]
    • Aspirin 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    • Ibuprofen 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  • Cholchicine add cholchicine to NSAIDs as first line treatment for viral/idiopathic acute and recurrent pericarditis to improve remission rates and prevent recurrence.[8]
    • Patients >70kg - 0.6mg PO BID x 3 months
    • Patients<70kg - 0.6mg PO Daily x 3 months
  • Glucocorticoid therapy second line agent for viral/idiopathic pericarditis, can consider low-moderate doses for patients with contraindications to NSAIDs or persistent symptoms despite appropriate therapy with NSAIDs + colchicine for at least 1 week. Also used for etiologies that are steroid responsive diseases.
    • Prednisone 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering[9]

Recurrent or Refractory

For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[10]

  • Colchicine
    • Patients >70kg - 0.6mg PO BID x 6 months
    • Patients<70kg - 0.6mg PO Daily x 6 months
    • If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

Contraindications to Colchicine[11]

  • Tuberculous
  • Neoplastic pericarditis
  • Liver disease or aminotransferase levels ≥1.5x upper limits of normal
  • Creatinine >2.5mg/dL (>221 umol/L)
  • Myopathy or CK > upper limits of normal
  • Inflammatory bowel disease
  • Life expectancy ≤18 months
  • Pregnancy or lactation

Uremic Pericarditis

  • The definitive treatment is dialysis

Tamponade

Disposition

  • Hospitalization is not necessary in most cases
  • Consider admission for:
    • Patients likely to have a specific cause (i.e. uremia, malignancy)
    • Subacute onset over weeks
    • Fever >100.4
    • Large effusion (echo-free space>20mm)
    • Cardiac tamponade
    • Immunosupressed
    • Anticoagulant use
    • Failure to respond to NSAIDs (>7dy)
    • Elevated cardiac enzymes (suggesting myopericarditis)
    • Trauma

Complications

  • Pericardial Effusion and Tamponade
  • Recurence
    • Usually weeks to months after initial episode
    • Management is same
  • Constrictive Pericarditis
    • Related to etiology; increased risk with bacterial pericarditis, rare with viral/idiopathic etiology
    • Restrictive picture with pericardial calcifications on CXR, thickened on TTE
    • Treat with pericardial window

See Also

References

  1. ↑ LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
  2. ↑ Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA 2015;314(14):1498–506.
  3. ↑ LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. doi: 10.1056/NEJMcp1404070. Review.
  4. ↑ Wang K, Asinger RW, and Marriott HJL. ST-segment Elevation in Conditions Other than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35.
  5. ↑ Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.
  6. ↑ Chaubey VK and Chhabra L. Spodick’s Sign: A Helpful Electrocardiographic Clue to the Diagnosis of Acute Pericarditis. Perm J. 2014 Winter; 18(1): e122.
  7. ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
  8. ↑ ImazioM, BobbioM, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis. Circulation. 2005;112(13):2012-2016.
  9. ↑ Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.
  10. ↑ Imazio M.Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91.
  11. ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF
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