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Key Features

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Essentials of Diagnosis
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  • Chest pain made worse by deep inspiration and decreased by leaning forward

  • Fever and tachycardia

  • Shortness of breath

  • Pericardial friction rub

  • ECG with elevated ST segments

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General Considerations
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  • Defined as inflammation of the pericardium

  • Commonly related to a viral infection

    • Coxsackievirus

    • Mumps

    • Epstein-Barr

    • Adenovirus

    • Influenza

    • HIV

  • Purulent pericarditis

    • Results from bacterial infection

      • Pneumococci

      • Streptococci

      • Staphylococci

      • Haemophilus influenzae

    • Less common than viral causes but potentially life-threatening

  • In some cases, pericardial disease occurs in association with

    • Rheumatic fever

    • Rheumatoid arthritis

    • Uremia

    • Systemic lupus erythematosus

    • Malignancy

    • Tuberculosis

  • Pericarditis after cardiac surgery (postpericardiotomy syndrome)

    • Most commonly seen after surgical closure of an ASD

    • Appears to be autoimmune in nature with high titers of antiheart antibody and evidence of acute or reactivated viral illness

    • Often self-limited

    • Responds well to short courses of aspirin or corticosteroids

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Clinical Findings

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  • Usually presents with sharp stabbing mid chest, shoulder, and neck pain

    • Pain is made worse by deep inspiration or coughing

    • Pain is decreased by sitting up and leaning forward

  • Shortness of breath and grunting respirations are common

  • Findings depend on the presence of fluid accumulation in the pericardial space (effusion)

    • In the absence of significant accumulation, a characteristic scratchy, high-pitched friction rub may be heard.

    • If the effusion is large, heart sounds are distant and muffled and a friction rub may not be present.

  • Cardiac tamponade

    • Occurs in association with a large effusion or one that has rapidly accumulated

    • Characterized by

      • Jugular venous distention

      • Tachycardia

      • Hepatomegaly

      • Peripheral edema

      • Pulsus paradoxus, in which systolic blood pressure drops > 10 mm Hg during inspiration

    • In the absence of cardiac tamponade, the peripheral, venous, and arterial pulses are normal

  • Decreased cardiac filling and subsequent decrease in cardiac output result in signs of right heart failure and the potential for cardiovascular collapse

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Diagnosis

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Imaging
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  • Radiography

    • Cardiac silhouette is enlarged when pericardial effusion is significant

    • Cardiac silhouette can appear normal if the effusion has developed over an extremely short period of time

  • Echocardiography

    • Serial echocardiography allows a direct, noninvasive estimate of the volume of pericardial fluid and its change over time

    • Doppler imaging demonstrates compression of the atria or respiratory alteration of ventricular inflow associated with cardiac tamponade

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Diagnostic Procedure
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  • Electrocardiography

    • ST segments are commonly elevated in acute pericarditis and PR segment depression may be present

    • Low voltages or electrical alternans (alteration in QRS amplitude between beats) can be seen with large pericardial effusions

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Treatment

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  • Depends on the cause of pericarditis and the size of the associated effusion

  • Viral pericarditis: nonsteroidal anti-inflammatory drugs improve symptoms

  • Purulent pericarditis requires

    • Immediate evacuation of the fluid

    • Appropriate antibiotic therapy

  • Percardiocentesis

    • Used to remove fluid in cardiac tamponade

    • Should also be considered if the underlying cause is unclear or identification of the pathogen ...

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