Pericarditis, Acute Inflammatory

Key Features

Essentials of Diagnosis

• Anterior pleuritic chest pain that is worse supine than upright

• Pericardial rub

• Fever common

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

• ECG reveals diffuse ST-segment elevation with associated PR depression

General Considerations

• 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

• COVID-19 has been associated with both acute pericarditis and even cardiac tamponade

• 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 ...