Updated: 2/2/2020

Pericarditis

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Snapshot
  • A 60-year-old woman presents with chest pain. She reports the chest pain started today and describes it as sharp and brief. When she sits up, the pain improves. She has no significant past medical history but endorses a viral respiratory infection a few days ago.  On physical exam, she is in no acute distress. She has a low-grade fever. An electrocardiogram shows widespread ST segment elevation and PR depression in the precordial leads. 
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 by inhalation
      • pain is also relieved by sitting up and leaning forward
    • shoulder pain (referred pain)
      • pericarditis is innervated by phrenic nerve
    • hypotension, tachycardia, and impaired diastolic filling in constrictive pericarditis 
  • Physical exam
    • may have a fever
    • friction rub
      • pathognomonic
    • Kussmaul sign 
      • seen in constrictive pericarditis
      • ↑ jugular venous distention on inspiration
Imaging
  • Transthoracic 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
    • distinguishing factor
      • pulsus paradoxus and Beck triad on exam
  • Myocardial infarction
    • distinguishing factor
      • more focal ST elevation on ECG suggestive of anatomic damage
Treatment
  • Nonoperative
    • observation and treatment of the underlying cause
      • indications
        • in cases of asymptomatic or small pericardial effusion
      • medical treatment
        • 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 and cardiac tamponade
  • Operative
    • pericardiectomy
      • reserved for recurrent disease
Complications
  • Pericardial effusion and tamponade
 

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(M3.CV.16.30) A 68-year-old male is admitted to your care four days after coronary artery bypass grafting (CABG) for a myocardial infarction (MI). The patient has a history of insulin-controlled diabetes, hypertension, and hyperlipidemia. Of note, the patient states that after the surgery, he had resolution of his chest pain, but he has started experiencing chest pain again. The patient states that the pain is exacerbated by deep breaths but feels better when he leans forward compared to lying down flat. On exam, his vitals are normal, and there are no murmurs heard on auscultation. His CK-mB returns as normal, and his repeat electrocardiogram (ECG) is shown in Figure A. What is the most likely diagnosis for this patient? Tested Concept

QID: 102971
FIGURES:
1

Ventricular aneurysm

0%

(0/3)

2

Ventricular septal rupture

0%

(0/3)

3

Papillary muscle rupture

0%

(0/3)

4

Acute pericarditis

67%

(2/3)

5

Dressler's syndrome

33%

(1/3)

M 10 C

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(M2.CV.15.37) A 29-year-old woman is admitted with a two-day history of chest pain. The pain is sharp, worsens with inspiration or coughing, and improves when leaning forward. On further review, she endorses a polyarticular arthritis and has had two first-trimester spontaneous abortions. Her vitals are as follows: T 100.9 F, HR 101, BP 115/70, RR 14, SpO2 96% on room air. On exam, you auscultate a superficial squeaking sound along the anterior chest, best heard with the diaphragm of the stethoscope. You order an ECG and chest radiograph, which are pictured in Figure A and Figure B respectively. Which of the following laboratory tests would assist in your diagnosis? Tested Concept

QID: 104043
FIGURES:
1

Complete blood count (CBC)

15%

(4/26)

2

Rheumatoid factor (RF)

8%

(2/26)

3

Antinuclear antibody (ANA)

73%

(19/26)

4

Parathyroid hormone (PTH)

0%

(0/26)

5

Antineutrophil cytoplasmic antibody (ANCA)

0%

(0/26)

M 6 C

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(M3.CV.15.32) A 59-year-old woman presents to the emergency department with severe chest pain and shortness of breath. She reports that she was walking in her house when the pain began and it worsened when she laid down to go to bed later in the evening. She experiences relief of the chest pain when she sits down and leans forward with her chest over her knees. She was discharged from the hospital earlier today after suffering from an ST-elevation myocardial infarction 2 days ago that was successfully treated with coronary revascularization. Her past medical history is significant for hypertension and rheumatoid arthritis. Her temperature is 97.9°F (36.6°C), blood pressure is 155/105 mm Hg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical examination is significant for a friction rub on cardiac auscultation and an estimated jugular venous pressure of 11 cm H2O. An electrocardiogram is obtained and shown in Figure A. An echocardiogram is obtained and reveals good contractile function of the heart with an ejection fraction of 60% as well as the finding shown in Figure B. A chest radiograph reveals a cardiac silhouette within normal limits. Which of the following is the best management of this patient's condition? Tested Concept

QID: 102973
FIGURES:
1

Aspirin

0%

(0/1)

2

Pericardial window

100%

(1/1)

3

Pericardiectomy

0%

(0/1)

4

Pericardiocentesis

0%

(0/1)

5

Prednisone

0%

(0/1)

M 11 E

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(M2.CV.15.4043) A 65-year-old man presents to the emergency room with sharp chest pain and shortness of breath. He notes that he has been recovering from a gastrointestinal virus for the past several days, but that the chest pain was not present on previous days. During the physical exam, he notes that the pain seems to be decreased when he is seated and leaning forward. His systolic blood pressure is 150 mmHg on expiration and 141 mmHg on inspiration. An EKG is shown in Figure A. Assuming that the cause of this patient's cardiac condition is related to his recent viral illness, which of the following is the most appropriate treatment? Tested Concept

QID: 107016
FIGURES:
1

Ibuprofen

75%

(15/20)

2

Aspirin

5%

(1/20)

3

Intravenous solumedrol

5%

(1/20)

4

Dialysis

0%

(0/20)

5

Urgent pericardiocentesis

10%

(2/20)

M 7 E

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Evidence (17)
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