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Pericarditis

Summary

Pericarditis is inflammation of the pericardium that may be acute or chronic. Acute pericarditis is most commonly caused by viral infection; however, a number of conditions can cause an inflammatory response in the pericardium. Acute inflammation typically manifests with fever, pleuritic chest pain, and a pericardial friction rub 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-limited, lasting days to weeks, and is therefore managed symptomatically. If pericarditis lasts longer than three months, it is described as chronic pericarditis. Chronic pericarditis may either be constrictive or effusive-constrictive. Constrictive pericarditis is characterized by thickening and rigidity of the pericardium, resulting in both backward and forward failure. Patients typically present with fatigue, jugular vein distention, peripheral edema, and a characteristic pericardial knock on auscultation, which is caused by a sudden stop in ventricular diastolic filling. Effusive-constrictive pericarditis is characterized by a thickened pericardium with an effusion; this can lead to cardiac tamponade. It may manifest with symptoms similar to constrictive pericarditis, symptoms of pericardial effusion, or cardiac tamponade. In both constrictive and effusive-constrictive pericarditis, imaging is used to confirm the diagnosis. Management consists of treatment of heart failure (e.g., diuretics) and pericardiectomy.

Definition

Etiology

Clinical features

Acute pericarditis [6]

Chronic pericarditis

Constrictive pericarditis [6][5]

Effusive-constrictive pericarditis [4]

Effusive-constrictive pericarditis; is characterized by symptoms of chronic constrictive pericarditis, pericardial effusion, or a mixture of both.

  • Smaller or slow-growing effusions: Patients may be asymptomatic.
  • Large effusions or rapidly growing effusions: symptoms of cardiac tamponade

Diagnostics

Acute pericarditis [5]

Approach

  • Check ECG, TTE to determine if diagnostic criteria are met.
  • If TTE is inconclusive, consider CT or cardiac MRI to confirm pericardial inflammation/effusion.
  • Determine whether any further diagnostic evaluation is indicated based on suspected etiology (see “Additional diagnostic evaluation” below).

Diagnostic criteria for acute pericarditis [4]

At least two of the following four criteria must be present for a diagnosis of acute pericarditis:

  1. Characteristic chest pain
  2. Pericardial friction rub
  3. Typical ECG changes (see below)
  4. New or worsening pericardial effusion

ECG

Not all patients go through all stages and manifestations may vary. In particular, pericarditis due to uremia may not involve characteristic ECG changes. [11]

  • Stage 1: diffuse ST elevations; , ST depression in aVR and V1; , PR segment depression
  • Stage 2: ST segment normalizes in ∼ 1 week.
  • Stage 3: inverted T waves
  • Stage 4: ECG returns to normal baseline (as prior to onset of pericarditis) after weeks to months.

In contrast to myocardial infarction, pericarditis is characterized by a diffuse distribution of ST elevations on ECG.

Imaging [4][5]

The goal of imaging is to identify any new pericardial effusion and rule out alternative etiologies.

Laboratory studies

Elevation of inflammatory markers may support the diagnosis of pericarditis but are not considered to be a part of the diagnostic criteria. [4]

Additional diagnostic evaluation

Chronic pericarditis

The diagnostic approach and findings for chronic pericarditis are similar to acute pericarditis but ECG, echocardiography, and imaging findings may vary.

  • Additional laboratory studies
  • Investigation of the underlying cause: See “Additional diagnostic evaluation” above.

Constrictive pericarditis [6][5]

The diagnosis of constrictive pericarditis is based on characteristic imaging findings (most commonly echocardiography but MRI and CT may be used).

Effusive-constrictive pericarditis

The diagnostic findings of effusive-constrictive pericarditis are similar to those of pericardial effusion, with the exception that in addition to pericardial effusion, pericardial thickening may also be seen. Elevation of right atrial pressures despite pericardiocentesis is strongly suggestive of effusive-constrictive. [18]

Treatment

The mainstays of therapy include anti-inflammatories to control pain and prevent a recurrence, and treatment of the underlying cause (if found).

Medical therapy

Acute pericarditis is often self-limited; but NSAIDs can alleviate symptoms and prevent a recurrence. Consider anti-inflammatory therapy also for chronic pericarditis (transient constrictive pericarditis may respond). [10]

Additional considerations

Beta blockers and calcium channel blockers should be avoided in constrictive pericarditis, as they may worsen heart failure by slowing a compensatory tachycardia!

Surgical therapy

Admission criteria [10][6][4][25]

Acute management checklist

  • ABCDE assessment
  • Check ECG and TTE.
  • Rule out life-threatening differential diagnoses (see chest pain).
  • Unstable patients: immediate pericardiocentesis if there is evidence of tamponade (see acute management checklist for tamponade)
  • Consider indications for advanced imaging/diagnostics.
  • Start NSAID therapy (if no contraindications).
  • Consider colchicine, prednisone, gastroprotective therapy.
  • Identify and treat the underlying cause.
  • Limit strenuous exercise.
  • Consider cardiology consult for severe cases.
  • Consider indications for admission.
  • If the patient is discharged, arrange for a follow-up in 1 week.

Complications

We list the most important complications. The selection is not exhaustive.

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last updated 06/11/2020
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