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Snapshot
  • A 60-year-old woman presents with chest pain. She has no significant past medical history, but recently did endorse a quick viral respiratory infection a few days ago. She reports the chest pain starting today and describes it as sharp and brief. When she sits up, the pain improves. On physical exam, she is in no acute distress. She has a low-grade fever. An electrocardiogram shows widespread ST elevation and PR depression in the precordial leads. She is given NSAIDs for her pericarditis.
Introduction
  • Clinical definition
    • inflammation of the pericardium characterized by sharp pain worsened by inhalation
  • Etiology  
    • serous
      • autoimmune disease
        • systemic lupus erythematosus
        • rheumatoid arthritis
      • uremia
      • viral illness
        • coxsackievirus
    • fibrinous pericarditis 
      • complication of myocardial infarction
        • 1-3 days after and several weeks after (Dressler syndrome)
      • uremia
      • rheumatic fever
    • hemorrhagic
      • tuberculosis
      • malignancy
    • constrictive
      • radiation therapy
      • open heart surgery
      • viral illness
      • tuberculosis
  • Pathogenesis
    • inflammation of the pericardium can cause chest pain
    • movement of the heart can cause friction between the 2 pericardial layers, producing a friction rub
    • inflammation may cause a pericardial effusion
  • Prognosis
    • can be acute or chronic, and may recur
    • viral pericarditis is usually self-limited
Presentation
  • Symptoms
    • sharp pleuritic chest pain that is worsened with inhalation
      • pain is also relieved by sitting up and leaning forward
    • shoulder pain (referred pain)
      • pericarditis is innervated by phrenic nerve
  • Physical exam
    • may have a fever
    • friction rub
      • pathognomonic
    • Kussmaul sign 
      • seen in constrictive pericarditis
      • ↑ jugular venous distention on inspiration
    • no pulsus paradoxus
Imaging
  • Echocardiography
    • indication
      • to assess for pericardial effusion and cardiac tamponade
  • Radiography
    • indication
      • to rule out pneumonia or other pulmonary pathology
    • findings
      • constrictive pericarditis may have pericardial calcifications on radiography
Studies
  • Labs
    • ↑ erythrocyte sedimentation rate
    • ↑ C-reactive protein
    • may have ↑ troponin I
  • Electrocardiogram (ECG) 
    • PR segment depression, especially in lead II, and in all leads except aVR
    • widespread ST segment elevation
    • upright T waves
      • weeks after pericarditis, this will become inverted T waves
    • classic ECG signs may be absent in uremic pericarditis
  • Making the diagnosis
    • based on clinical presentation and ECG findings
Differential
  • Cardiac tamponade, hemopericardium, heart failure, MI, pneumonia, pneumothorax
Treatment
  • Nonoperative
    • observation & treatment of underlying cause
      • indications
        • in cases of asymptomatic or small pericardial effusion
      • medical treatment of underlying condition
        • NSAIDS 
          • for viral pericarditis
        • steroids and immunosuppressants
          • for SLE
          • avoid immediately following MI to protect from ventricular wall rupture
        • dialysis
          • for uremia
        • aspirin
          • for post-MI pericarditis
    • pericardiocentesis
      • indications
        • required for large effusions & cardiac tamponade
  • Operative
    • pericardiectomy
      • reserved for recurrent disease
Complications
  • Pericardial effusion and tamponade
 

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