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For further information, see CMDT Part 10-31: Acute Inflammatory Pericarditis

KEY FEATURES

Essentials of Diagnosis

  • Anterior pleuritic chest pain that is worse supine than upright

    • Pericardial rub

    • Fever common

    • Erythrocyte sedimentation rate (ESR) or inflammatory C-reactive protein (CRP) usually elevated

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

General Considerations

  • Causes

    • Infectious causes

      • Viral infections are the most common cause (coxsackieviruses, echoviruses, influenza, Epstein-Barr, varicella, hepatitis, mumps, HIV, COVID-19); acute pericarditis often follows upper respiratory tract infection

      • COVID-19 has been associated with acute pericarditis and cardiac tamponade; men aged < 50 years are most commonly affected

      • Tuberculosis

      • Bacterial infections (direct extension from pulmonary infections or primary infection (pneumococci)

      • Lyme disease (caused by Borrelia burgdorferi)

    • Systemic diseases

      • Uremia

      • Connective tissue diseases (eg, systemic lupus erythematosus, rheumatoid arthritis)

      • Myxedema (hypothyroidism)

    • Neoplasm

      • Spread of adjacent lung cancer

      • Invasion by breast cancer, renal cell carcinoma, Hodgkin disease, lymphomas

    • Drug toxicity (eg, minoxidil, penicillins, clozapine)

    • Hemopericardium

    • Postcardiac surgery

    • Contiguous inflammatory processes in the myocardium or lung

    • Radiation

      • Usually after treatment involving the heart with doses > 4000 cGy and > 30% of the heart

    • Pericardial injury from invasive cardiac procedures

    • Implantation of intracardiac devices (eg, cardiac pacemakers, defibrillators, ASD occluder devices)

    • Inflammatory reaction to transmural myocardial necrosis (post-MI or postcardiotomy pericarditis [Dressler syndrome])

  • The European Society of Cardiology's four diagnostic categories of pericarditis:

    • Acute, if 2 of 4 are present: (1) pericardial chest pain, (2) pericardial rub, (3) new widespread ST elevation or PR depression, and (4) new or worsening pericardial effusion

    • Incessant: Defined by its duration; it lasts > 4–6 weeks but < 3 months without remission

    • Recurrent: One reported episode of pericarditis after being symptom-free for at least 4–6 weeks

    • Chronic: Pericarditis persists for > 3 months

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

    • Tuberculous pericarditis

      • Rare in developed countries; results from direct lymphatic or hematogenous spread

      • Pericardial effusions are usually small or moderate but may be large when chronic

      • Clinical pulmonary involvement may be absent or minor, although associated pleural effusions are common

      • Nonspecific symptoms (fever, night sweats, fatigue) may be present for days to months

      • Pericardial involvement occurs in 1–8% of patients with pulmonary tuberculosis

    • 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, there may be hemodynamic compromise

  • Post-MI or postcardiotomy pericarditis (Dressler syndrome)

    • Occurs days to weeks to several months after MI or open heart surgery

    • May be recurrent

    • Probably represents an autoimmune syndrome

    • Patients present with typical pain, fever, malaise, and leukocytosis

    • Joint pain and fever rarely occur

    • Tamponade is rare post-MI but not postoperatively

  • Radiation pericarditis

    • Onset within ...

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