Pericarditis

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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

Clinical Findings

• 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

Diagnosis

Imaging

• 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

Diagnostic Procedure

• 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

Treatment

• 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 ...