- Clinical science
Acute pericarditis is an inflammation of the pericardium that is most commonly caused by infection or myocardial infarction, or occurs following cardiac surgery. The condition typically presents with fever, pleuritic chest pain, and a pericardial friction rub heard on auscultation. The diagnosis is established based on clinical findings, although diffuse ST segment elevations on ECG and imaging may support the diagnosis. Acute pericarditis is usually self-limiting within 2–6 weeks and is therefore managed symptomatically. Constrictive pericarditis occurs as a complication of acute pericarditis and is characterized by thickening and rigidity of the pericardium, resulting in both backward and forward failure. Accordingly, patients present with fatigue, jugular vein distention, peripheral edema, and a characteristic pericardial knock on auscultation, caused by a sudden stop in ventricular diastolic filling. Diagnostic imaging shows typical pericardial thickening on chest x-ray and reduced blood flow on echocardiography. Management consists of treatment of heart failure (e.g., diuretics) and pericardiectomy.
- Acute pericarditis is inflammation of the pericardium that either occurs as an isolated process or with concurrent myocarditis. Conditions that primarily affect the pericardium are referred to as myopericarditis, those which predominantly affect the myocardium as perimyocarditis. However, these terms are often used interchangeably.
- Constrictive pericarditis is characterized by compromised cardiac function caused by a thickened, rigid, and fibrous pericardium secondary to acute pericarditis.
- Myocardial infarction: pericarditis may occur either within 1–3 days as an immediate reaction (i.e., post-infarction fibrinous pericarditis), or weeks to months following an acute myocardial infarction ().
- Postoperative (post-pericardiotomy syndrome): blunt or sharp trauma to the pericardium
- Collagen vascular disease: systemic lupus erythematosus, rheumatoid arthritis
- Other causes: renal failure (uremia), tumors (Hodgkin lymphoma), radiation, sarcoidosis
- Low-grade intermittent fever, tachypnea, dyspnea, nonproductive cough
- Chest pain: often sharp, pleuritic; improves on sitting and leaning forward
- Pericardial friction rub: high-pitched scratching sound best heard on auscultation over the left sternal border during expiration while the patient is sitting up and leaning forward
- Symptoms of fluid overload (backward failure)
- Symptoms of reduced cardiac output (forward failure)
- Blood tests: CBC (leukocytosis), ↑ troponin I, ↑ ESR, ↑ CRP, abnormal renal parameters (BUN, creatinine, electrolytes) if caused by underlying uremia
- Typical ECG changes: not present in uremic pericarditis
- Echocardiography: often normal; possibly signs of effusion
- Chest x-ray normal
- Chest x-ray (best initial test); , CT, and MRI: pericardial thickening and calcifications, normal cardiac silhouette
- ↑ Pericardial thickness
- Abnormal ventricular filling with sudden halt during early diastole
- Pronounced respiratory variation in ventricular filling: across the tricuspid valve, velocity of blood flow increases with inspiration by > 40% (due to constriction), whereas across the mitral valve, velocity of blood flow decreases with inspiration by > 25% (due to a decrease in relaxation of the left ventricle)
- Moderate biatrial enlargement
- Excludes and
ECG shows no conclusive findings.
- Atrial fibrillation can occur in severe disease.
- Elevated diastolic pressures in the left and right ventricles with diastolic equalization
- Mean right arterial pressure > 15 mm Hg
- Right ventricular end-diastolic pressure > ⅓ of the systolic pressure
Square root sign
- Also known as dip-and-plateau waveform
- Sudden dip of the right and left ventricular pressure in early diastole followed by a plateau during the last stage of diastole
Acute pericarditis is often self-limiting and resolves within approx. 2–6 weeks.
- Treat underlying cause
- Restricted physical activity
- NSAIDs plus colchicine (alleviates symptoms, reduces rate of recurrence)
- Glucocorticoids if NSAIDs are ineffective
- Treat underlying condition
- Symptomatic therapy; (manage fluid overload with diuretic therapy)
- Pericardiectomy (complete removal of the pericardium)
We list the most important complications. The selection is not exhaustive.