ACUTE PERICARDITIS

Normal pericardial function: 15-50mL ultrafiltrate, prevents sudden dilation of heart, facilitates atrial filling during systole, restricts anatomy, lubricates, retards spread of infection.

Clnical features: Chest pain

1. Typically retrosternal or L precordial

2. Referred to back and trapezius ridge

3. Pleuritic and positional, worse w/ recumbency, better with sitting and leaning forward

4. May be very similar to MI

5. May be absent in TB, postirradiation, neoplastic, uremic

Physical exam:

1. Pericardial friction rub, best heard leaning forward at LLSB

2. Pulsus paradoxus (IF tamponade)

Labs/studies:

1. Moderate rises in CK/MB may occur

2. EKG: see below

3. ECHO

4. Pericardiocentesis: indicated with tamponade, or for diagnosis of infectious pericarditis

Differential diagnosis:

1. Infectious

a. Viral

b. Pyogenic-CT operations, immunosuppression, rupture of esophagus, rupture of ring abcess, uncommonly 2ndary to pneumococcal pneumonia

c. Tuberculous

d. Mycotic

e. Other (syphilitic, parasitic)

1. Non-infectious

a. Acute MI

b. Uremia

c. Neoplasia

d. Myxedema

e. Cholesterol

f. Chylopericardium

g. Trauma

h. Aortic aneurysm-leakage into pericardial sac

i. Postirradiation

j. Associated with ASD

k. Associated with severe chronic anemia

l. Infectious mononucleosis

m. Familial mediterranean fever

n. Familal pericarditis

o. Sarcoidosis

p. Acute idiopathic

1. Hypersensitivity/autoimmune

a. Rheumatic fever-severe pancarditis, murmurs

b. Collagen vascular disease-SLE, RA, Scleroderma

c. Drug-induced-Procainamide, Hydralazine

Postcardiac- post-MI(Dressler’s), postpericardiotomy

Treatment:

1. Bed rest until pain, fever resolve

2. Avoid anticoagulants to reduce risk of hemorrhagic transformation

3. Monitor for effusion/tamponade

Viral/Idiopathic acute pericarditis: diagnosis of exclusion

1. Etiologies- coxsackie A/B, influenza, echovirus type 8, mumps, HSV, chickenpox, adenovirus

2. Clinical features- May be antecedent URI, serologic studies or viral isolation from effusion may be suggestive. Fever and pain occur simultaneously (compared with MI where pain comes first)

3. Labs- ESR elevated, granulocytosis followed by lymphocytosis is common

4. Usually runs course in few days, but may recur

5. Treatment:

a. Bed rest

b. Anti inflammatory agents- ASA up to 900 QID, Indocin 25-75 QID, prednisone 20-80 QD, taper once pt is afebrile and assx X 1 wk.

1. Pericardectiomy- for multiple, frequent, debilitating recurrences

EKG CHANGES IN PERICARDITIS

Stage	Changes on EKG
Stage I	Diffuse concave-up ST elevation w/ concordant TWs; ST depression in aVR or V1; PR depression; low voltage; absence of reciprocal ST changes
Stage II	STs return to baseline; TW flattening
Stage III	TW inversion
Stage IV	Gradual resolution of TWI

COMPARISON OF EKG CHANGES

EKG	Pericarditis	MI	Early repol
ST shape	Concave up	Convex up	Concave up
QWs	Absent	Present	Absent
Reciprocal ST changes	Absent	Present	Absent
ST elev location	Limb and precord	Area of artery	Precordial
ST/T ration in V6	> 0.25	N/A	< 0.25
Loss of RW voltage	Absent	Present	Absent
PR depression	Present	Absent	Absent

Amer Fam Phys.57(4): 699-704, 1998