Updated: 9/12/2018

Pericarditis

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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
      • 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 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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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.209) A 34-year-old Caucasian female presents at the ER with fever and sharp pain in her chest upon coughing and inhalation. Three weeks earlier she presented to her rheumatologist with a butterfly rash, joint pain and fatigue and was given a diagnosis of systemic lupus erythematosus. A friction rub is present upon physical exam. Which of the following do you most suspect in this patient? Review Topic

QID: 100725
1

Pulmonary hypertension

0%

(0/7)

2

Interstitial lung disease

0%

(0/7)

3

Acute myocardial infarction

0%

(0/7)

4

Pericarditis

100%

(7/7)

5

Pericardial tamponade

0%

(0/7)

M1

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PREFERRED RESPONSE 4

(M1.CV.104) A 35-year-old Caucasian female with a history of rheumatoid arthritis presents to your clinic with pleuritic chest pain that improves while leaning forward. Which of the following additional findings would you expect to observe in this patient? Review Topic

QID: 100620
1

Increase in jugular venous pressure on inspiration

35%

(33/95)

2

Exaggerated amplitude of pulse on inspiration

19%

(18/95)

3

Pulsatile abdominal mass

5%

(5/95)

4

Continuous machine-like murmur

11%

(10/95)

5

S3 heart sound

22%

(21/95)

M1

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PREFERRED RESPONSE 1
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(M1.CV.37) A 45-year-old African-American woman presents with dyspnea, cough, and non-radiating chest pain. Her chest pain is relieved by leaning forward and worsens upon leaning backwards. A scratchy rub is heard best with the patient leaning forward. Physical examination did not elucidate evidence of a positive Kussmaul's sign, pulsus paradoxus, or pericardial knock. The patient most likely is suffering from which of the following? Review Topic

QID: 100553
1

Cardiac tamponade

3%

(1/30)

2

Constrictive pericarditis

17%

(5/30)

3

Acute pericarditis

73%

(22/30)

4

Libman-Sacks endocarditis

3%

(1/30)

5

Acute myocardial infarction

3%

(1/30)

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(M1.CV.30) A 35-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient? Review Topic

QID: 100546
1

Pain improves with inspiration

6%

(5/78)

2

Pain relieved by sitting up and leaning forward

51%

(40/78)

3

High-pitched diastolic murmur

18%

(14/78)

4

Displaced apical impulse

9%

(7/78)

5

Mid-systolic click

15%

(12/78)

M1

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