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Snapshot
  • A 58-year-old woman with a past medical history of systemic lupus erythematosus presents to the emergency room for sharp chest pain. She reports that it is worse with inspiration and gets better when she leans forward. On physical exam, there is a friction rub that is loudest when she leans forward. An electrocardiogram shows widespread ST elevation.
Introduction
  • Clinical definition
    • inflammation of the pericardium characterized by sharp pain worsened by inhalation
  • Etiology
    • serous
      • autoimmune disease
        • systemic lupus erythematosus  
        • rheumatoid arthritis
      • uremia
      • viral illness
        • coxsackievirus
    • fibrinous pericarditis
      • complication of myocardial infarction (MI)
        • 1-3 days after and several weeks after (Dressler syndrome) the MI
      • uremia
      • rheumatic fever
    • hemorrhagic
      • tuberculosis
      • malignancy
    • constrictive
      • radiation therapy
      • viral illness
      • tuberculosis
  • Pathogenesis
    • inflammation of the pericardium can cause chest pain
      • movement of the heart can cause friction between the 2 pericardial layers, producing a friction rub
      • inflammation may cause a pericardial effusion
  • Prognosis
    • can be acute or chronic, and may recur
    • viral pericarditis is usually self-limited
Presentation
  • Symptoms
    • sharp pleuritic chest pain that is worsened by inhalation
      • pain is also relieved by sitting up and leaning forward
    • shoulder pain (referred pain)
      • pericarditis is innervated by phrenic nerve
  • Physical exam
    • may have a fever
    • friction rub
      • pathognomonic
    • Kussmaul sign
      • seen in constrictive pericarditis
      • ↑ jugular venous distention on inspiration
Imaging
  • Echocardiography  
    • indication
      • to assess for pericardial effusion and cardiac tamponade
  • Radiography
    • indication
      • to rule out pneumonia or other pulmonary pathology
    • findings
      • constrictive pericarditis may have pericardial calcifications on radiography
Studies
  • Labs
    • ↑ erythrocyte sedimentation rate
    • ↑ C-reactive protein
    • may have ↑ troponin I
  • Electrocardiogram (ECG)
    • PR segment depression and in all leads except aVR but especially in lead II
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    • widespread ST segment elevation
    • upright T waves
      • weeks after pericarditis, this will become inverted T waves
    • classic ECG signs may be absent in uremic pericarditis
  • Making the diagnosis
    • based on clinical presentation and ECG findings
Differential
  • Cardiac tamponade
    • distinguishing factor
      • pulsus paradoxus and Beck triad on exam
  • Myocardial infarction
    • distinguishing factor
      • more focal ST elevation on ECG suggestive of anatomic damage
Treatment
  • Conservative
    • restriction of exercise
      • indication
        • for all patients
  • Medical
    • nonsteroidal anti-inflammatory drugs (NSAIDs)
      • indication
        • best initial therapy
      • drugs
        • indomethacin
        • naproxen
        • ibuprofen
        • aspirin
    • prednisone
      • indication
        • pain refractory to NSAIDs
    • colchicine
      • indication
        • adjunct therapy to NSAIDs or steroids
  • Non-operative
    • pericardiocentesis
      • indication
        • in patients with pericardial effusion or cardiac tamponade
    • dialysis
      • indication
        • for patients with pericarditis from uremia
Complications
  • Pericardial effusion and tamponade
 

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