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Key Features

  • Causes

    • Infections

    • Autoimmune diseases

    • Uremia

    • Neoplasms

    • Radiation

    • Drug toxicity

    • Hemopericardium

    • Postcardiac surgery

    • Contiguous inflammatory processes of the heart or lung (eg, myocardial infarction [MI], Dressler syndrome, idiopathic)

  • Viral infections are the most common cause; acute pericarditis often follows upper respiratory tract infection

  • Males, usually younger than age 50, are most commonly affected

Clinical Findings

  • Often associated with pleuritic chest pain, relieved by sitting, that radiates to the neck, shoulders, back, or epigastrium

  • Dyspnea and fever

  • Pericardial friction rub with or without evidence of pericardial effusion or constriction

  • Pericardial involvement

  • Tuberculous pericarditis: subacute; symptoms may be present for days to months

  • Bacterial pericarditis: rare; patients appear toxic and are often critically ill

  • Uremic pericarditis: symptoms may or may not be present; fever is absent

  • Neoplastic pericarditis: often painless, hemodynamic compromise

  • Dressler syndrome (post-MI pericarditis)

    • Occurs within days to 3 months post-MI

    • Usually self-limited

Diagnosis

  • Usually clinical

  • Leukocytosis

  • ECG

    • Generalized ST-T wave changes, characteristic progression beginning with diffuse ST elevations, followed by a return to baseline, then T wave inversions

    • PR depression indicates atrial injury

  • Chest radiograph

    • Frequently normal

    • Cardiac enlargement if pericardial effusion

    • Signs of related pulmonary disease

  • Echocardiogram

    • Often normal in inflammatory pericarditis

    • Otherwise, can demonstrate pericardial effusion, tamponade

  • Erythrocyte sedimentation rate or inflammatory C-reactive protein usually elevated

  • The American Society of Echocardiography proposes adding an elevated C-reactive protein and late gadolinium enhancement of the pericardium to confirmatory diagnostic criteria

  • Screening chest CT or MRI is often recommended to ensure there is no extracardiac diseases contiguous to the pericardium

  • PET scanning can also be used to help define pericardial inflammation

  • Rising titers in paired sera may confirm viral infection but are rarely done

  • Cardiac enzymes slightly elevated if there is an epicardial myocarditis component

  • Cytology of pericardial effusion or pericardial biopsy may be helpful

  • Usually data from a diagnostic pericardial tap is unhelpful in diagnosis

  • MRI and CT scan can visualize adjacent tumor when present

Treatment

  • Restrict activity until symptom resolution; for athletes, exercise should be restricted until symptoms resolve and all laboratory tests are normal (generally 3 months)

  • The 2015 European Society of Cardiology guidelines

    • Aspirin, 750–1000 mg every 8 hours for 1–2 weeks, tapering the dose by 250–500 mg every 1–2 weeks or

    • Ibuprofen, 600 mg every 8 hours for 1–2 weeks, tapering the dose by 200–400 mg every 1–2 weeks

    • Gastroprotection should be included

  • Colchicine

    • Initial treatment of the acute episode helps prevent recurrences

    • Should be added to the NSAID at 0.5–0.6 mg once daily for patients < 70 kg or twice daily for patients > 70 kg and continued for 3 months

    • In all refractory and recurrent cases, colchicine should also be the initial therapy and used for at least 6 months

    • The C-reactive protein is used to assess the effectiveness of therapy and, once normalized, tapering is initiated

    • Tapering of colchicine is not mandatory

  • Indomethacin, 25–50 ...

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