Pericarditis

Pericarditis10[1]

Pericarditis is the inflammation of the pericardium which can result from a wide range of infectious and non-infectious causes.


Presentation

History

The salient symptom of pericarditis (resulting from any etiology) is sharp, retrosternal chest pain that may radiate towards the shoulders and neck. Typically, the pain is relieved by sitting forward and exaggerated by lying supine. Deep inspiration, coughing and sneezing also sharply exaggerate the pain.
Depending upon the etiology, non-specific symptoms such as fever, chills and sweating may also be present.

Physical examination

The diagnostic sign of pericarditis on physical examination is friction rub. It is heard on auscultation as a superficial, scratching sound localized to a small area of the precordium, usually in systole. The sound is best heard when at expiration with the patient leaning forward. Tachycardia may also be present.

Workup

Laboratory tests

  • Complete blood count (CBC): Complete blood count may reveal an increase in the number of leukocytes.
  • Erythrocyte sedimentation rate (ESR): Erythrocyte sedimentation rate is raised in pericarditis.
  • C reactive protein: C reactive protein is an inflammatory marker and may be raised in pericarditis.
  • Viral titers: Raised viral titers may be present when pericarditis has a viral etiology.
  • Tuberculin skin test: This test is helpful in diagnosing pericarditis caused by Mycobacterium tuberculosis.
  • Antinuclear antibody (ANA) and rheumatoid factor: The level of these factors may be tested if autoimmune etiology is suspected.

Electrocardiography

Electrocardiogram shows ST segment elevation with upward concavity [6]. These changes evolve through the following 4 stages [7].

  • Stage I: In this stage, there is a diffuse elevation of ST segment with and depression of PR segment.
  • Stage II: This stage is characterized by normalization of the ST and PR segments.
  • Stage III: In stage III, there are widespread T wave inversions.
  • Stage IV: In stage IV, there is normalization of T waves.

Imaging

Procedures

Pericardial fluid examination and pericardial biopsy: Examination of the pericardial fluid and biopsy of the pericardium can yield useful information regarding the etiology.

Treatment

The goals of treatment in acute pericarditis are to reduce the pain and prevent the development of complications [8].

Non-steroidal anti-inflammatory drugs (NSAIDS) are the first line agents for the reduction of pain and inflammation in acute pericarditis [9]. Ibuprofen, aspirin and indomethacin are the NSAIDs commonly used. The duration of treatment is 1 to 2 weeks, however in case of recurrences, they are continued for up to 4 weeks. Since these drugs have a tendency to cause gastric bleeding with chronic use, they should be used in combination with misoprostol to prevent this adverse effect.

If the pain of pericarditis is not sufficiently reduced by the use of NSAIDs, corticosteroids such as prednisolone may also be used. A dose of 60 mg is given for 2 days. This dose is then tapered over a period of 2 weeks.

If steroid therapy is to be avoided, colchicine can be given for 3 months as an alternative adjunct to NSAIDs [10]. It is known to reduce the symptoms and prevent recurrences.

Prognosis

Pericarditis is mostly a benign, self-limiting disease with a very good prognosis. The signs and symptoms of uncomplicated pericarditis usually resolve by 1 to 2 weeks [4]. Recurrence occurs in up to 24% of the patients, usually within the first week after the initial episode.

Certain complications can prolong the duration of the disease and may even prove fatal. Cardiac tamponade, constrictive pericarditis and effusive-constrictive pericarditis are the troublesome complications of this disease [5].

Etiology

Pericarditis can result from a wide range of infectious and non-infectious causes.

The common infectious causes include viruses (such as coxsackievirus, echovirus and adenovirus) and Mycobacterium tuberculosis [1] [2]. Other less common causes include gram positive and gram negative bacteria, fungi (such as Blastomyces dermatitidis, Candida sp. and Histoplasma capsulatum). Parasites such as Echinococcus may also cause pericarditis.

The most common non-infective cause of pericarditis is myocardial infarction in which pericarditis develops 1 to 4 days after any acute attack.

Pericarditis can also be caused by infiltration of the pericardium by malignant cells arising from lung carcinoma, breast carcinoma, leukemias or lymphomas. Mediastinal and thoracic radiation for the treatment of these malignancies can also cause pericarditis.

Pericarditis can also result from certain autoimmune causes such as connective tissue disorders, systemic lupus erythematosus, scleroderma and rheumatoid arthritis. Renal failure leading to uremia may also cause the development of pericarditis [3].

Certain drugs such as doxorubicin, isoniazid, dantrolene, rifampin and phenytoin may also cause the development of pericarditis. Other etiologies include chest trauma and surgical procedures.

Epidemiology

There is not much epidemiological data available regarding pericarditis. However, surveys in various hospitals have revealed that pericarditis occurs in up to 5% of the people who present to the emergency departments with chest pain.

Sex distribution
Age distribution

Pathophysiology

Pericarditis is the acute or chronic inflammation of the pericardium. There may be associated serous, purulent or fibrinous exudate depending upon the etiology.

Prevention

Pericarditis results from a wide number of causes and therefore can not be prevented by specific guidelines. In general, good hygiene should be adopted, proper immunization should be done and the risk factors for myocardial infarction (such as smoking, unhealthy diet etc.) should be avoided.

Summary

Pericarditis is the inflammation of the pericardium – the fibroserous sac that surrounds the heart and the roots of the great vessels. It may occur due to infections, myocardial infarction, trauma, connective tissue disorders or malignant diseases. It is characterized by sharp retrosternal pain radiating to the neck and shoulders and typically exaggerating on deep breathing and coughing.

The prognosis of the patients suffering from pericarditis is very good. Drugs such as non-steroidal anti-inflammatory drugs, steroids and colchicine treat this condition and provide excellent relief from symptoms.

Patient Information

Pericarditis is the medical term to describe an inflammation of the fibrous sac that covers the heart. There are many causes of pericarditis but it usually occurs due to infection with viruses or as a complication of heart attack. The typical features of pericarditis include chest pain that is felt up to the level of the neck or shoulders. The pain increases in severity when the patient coughs or takes deep breaths. Pericarditis is usually not a dangerous condition and is managed easily by the use of painkilling medications.

Self-assessment

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References

  1. Kawecka-Jaszcz K. [Pericarditis: classification, etiology, pathogenesis]. Folia medica Cracoviensia. 1991;32(1-2):15-22.
  2. Purtskhvanidze Ch G, Georgadze AS, Givishvili UA. [Exudative pericarditis of tuberculous etiology]. Problemy tuberkuleza. 1986(11):63.
  3. Frei D, Willimann P, Binswanger U. [Uremic pericarditis. Etiology and symptoms]. Deutsche medizinische Wochenschrift. Nov 23 1979;104(47):1660-1661.
  4. Ilan Y, Oren R, Ben-Chetrit E. Acute pericarditis: etiology, treatment and prognosis. A study of 115 patients. Japanese heart journal. May 1991;32(3):315-321.
  5. Habib G. [Acute pericarditis. Etiology, diagnosis, course, complications, treatment]. La Revue du praticien. Jan 1 1997;47(1):91-96.
  6. Hannibal GB. ECG characteristics of acute pericarditis. AACN advanced critical care. Jul-Sep 2012;23(3):341-344.
  7. Masek KP, Levis JT. ECG diagnosis: acute pericarditis. The Permanente journal. Fall 2013;17(4):e146.
  8. Le Roux A. [Acute pericarditis: etiology, diagnosis, course, complications and treatment]. La Revue du praticien. Nov 15 1999;49(18):2049-2052.
  9. Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart failure reviews. May 2013;18(3):355-360.
  10. Cacoub PP. Colchicine for treatment of acute or recurrent pericarditis. Lancet. Jun 28 2014;383(9936):2193-2194.

Media References

  1. Pericarditis10, CC BY-SA 3.0

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