ACUTE PERICARDITIS

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ACUTE PERICARDITIS

• Emily O. Jenkins M.D.
• AM Report
• 7.13.09

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Incidence

• Exact incidence and prevalence are unknown
• Diagnosed in 0.1 of hospitalized patients and 5
  of patients admitted for non-acute MI chest pain
• Observational study 27.7 cases/100,000
  population/year

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Etiology Can be Tricky. . .

• Standard diagnostic evaluations are oftentimes
  relatively low yield
• One series elucidated a cause in only 16 of
  patients
• Leading possibilities
• Neoplasia
• Tuberculosis
• Non-tuberculous infection
• Rheumatic disease

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Initial clinical and echocardiographic evaluation
of patients with suspected acute pericarditis
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Diagnostic Criteria

• Chest pain anterior chest, sudden onset,
  pleuritic may decrease in intensity when leans
  forward, may radiate to one or both trapezius
  ridges
• Pericardial friction rub most specific, heard
  best at LSB
• EKG changes new widespread ST elevation or PR
  depression
• Pericardial effusion absence of does not exclude
  diagnosis of pericarditis
• Supporting signs/symptoms
• Elevated ESR, CRP
• Fever
• leukocytosis

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EKG
Electrocardiogram in acute pericarditis showing
diffuse upsloping ST segment elevations seen best
here in leads II, III, aVF, and V2 to V6. There
is also subtle PR segment deviation (positive in
aVR, negative in most other leads). ST segment
elevation is due to a ventricular current of
injury associated with epicardial inflammation
similarly, the PR segment changes are due to an
atrial current of injury which, in pericarditis,
typically displaces the PR segment upward in lead
aVR and downward in most other leads.
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Pericardial Effusion
Cardiomegaly due to a massive pericardial
effusion. At least 200 mL of pericardial fluid
must accumulate before the cardiac silhouette
enlarges.
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Tests

• EKG
• CXR
• PPD
• ANA
• HIV
• Blood cultures
• Urgent echocardiogram if evidence of pericardial
  effusion
• Not necessary
• Viral studies b/c yield is low and management is
  not altered

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Treatment

• NSAIDs PPI
• Aspirin (2-5 g/day)
• Ibuprofen (300-800 mg q6-8H)
• Ketorolac
• Theoretical concern that anti-platelet agents
  promote development of hemorrhagic pericardial
  effusion has not been substantiated
• Colchicine (0.5-1 mg/day) may prevent
  recurrence
• Glucocorticoids (prednisone 1 mg/kg/day) ?
  increased rate of complications. Should be
  restricted to
• Acute pericarditis due to connective tissue
  disease
• Autoreactive (immune-mediated) pericarditis
• Uremic pericarditis

NSAID of choice unless associated with acute MI,
where all non-ASA NSAIDs should be avoided
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Prognosis for acute idiopathic pericarditis

• Good long-term prognosis
• Cardiac tamponade is rare, but up to 70 in cases
  with specific etiologies (eg. Neoplastic,
  tuberculous, purulent)
• Constrictive pericarditis occurs in about 1 of
  patients
• 15-30 of patients not treated with colchicine
  develop either recurrent or incessant disease

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Recurrent Pericarditis

• Exact recurrence rate unknown
• Most cases considered to be autoimmune
• Risk Factors
• Lack of response to aspirin or other NSAID
• Glucocorticoid therapy
• Inappropriate pericardiotomy
• Creation of a pericardial window
• For some patients, symptoms can only be
  controlled with steroidal therapy

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Autoreactive Pericarditis diagnostic criteria

• Pericardial fluid revealing gt5000/mm3 mononuclear
  cells or antisarcolemmal antibodies
• Inflammation in epicardial/endomyocardial
  biopsies by gt14 cells/mm2
• Exclusion of active viral infection both in
  pericardial effusion and endocardial/epicardial
  biopsies
• Exclusion of tuberculosis, borrelia burgdorferi,
  chlamydia pneumoniae and other bacterial
  infection
• Absence of neoplastic infiltration in effusion
  and biopsy samples
• Exclusion of systemic, metabolic disorders and
  uremia

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Treatment

• Aspirin
• NSAIDs
• Colchicine can reduce or eliminate need for
  glucocorticoids
• Glucocorticoids should be avoided unless
  required to treat patients who fail NSAID and
  colchicine therapy
• Many believe that prednisone may perpetuate
  recurrences
• Intrapericardial glucocorticoid therapy sx
  improvement and prevention of recurrence in 90
  of patients at 3 months and 84 at one year
• Other immunosuppression
• Azothoprine (75-100 mg/day)
• Cyclophosphamide
• Mycophenolate anecdotal evidence only
• Methotrexate limited data
• IVIG limited data
• Pericardiectomy To avoid poor wound healing,
  recommended to be off prednisone for one year.
  Reserved for the following cases
• If gt1 recurrence is accompanied by tamponade
• If recurrence is principally manifested by
  persistent pain despite an intensive medical
  trial and evidence of serious glucocorticoid
  toxicity