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 systemic lupus erythematosus 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 in most leads except aVR where the reflections are opposite of all other leads lead II may show the most pronounced depressions leep <a target="_blank" href="https://www.medbullets.com/step1-stats/1030/sleep" rel="nofollow">www.medbullets.com/step1-stats/1030/sleep</a> widespread ST segment elevations 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