Updated: 8/1/2019

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 in most leads
      • except aVR where the reflections are opposite of all other leads
      • lead II may show the most pronounced depressions
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        <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
 

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(M1.CV.12.37) 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? Tested Concept

QID: 100553
1

Cardiac tamponade

1%

(1/96)

2

Constrictive pericarditis

15%

(14/96)

3

Acute pericarditis

78%

(75/96)

4

Libman-Sacks endocarditis

3%

(3/96)

5

Acute myocardial infarction

1%

(1/96)

M 2 D

Select Answer to see Preferred Response

(M1.CV.12.104) 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? Tested Concept

QID: 100620
1

Increase in jugular venous pressure on inspiration

47%

(90/192)

2

Exaggerated amplitude of pulse on inspiration

19%

(37/192)

3

Pulsatile abdominal mass

3%

(5/192)

4

Continuous machine-like murmur

7%

(14/192)

5

S3 heart sound

16%

(30/192)

M 2 E

Select Answer to see Preferred Response

(M1.CV.12.209) 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? Tested Concept

QID: 100725
1

Pulmonary hypertension

0%

(0/81)

2

Interstitial lung disease

0%

(0/81)

3

Acute myocardial infarction

0%

(0/81)

4

Pericarditis

98%

(79/81)

5

Pericardial tamponade

1%

(1/81)

M 2 D

Select Answer to see Preferred Response

(M1.CV.12.30) 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? Tested Concept

QID: 100546
1

Pain improves with inspiration

6%

(9/148)

2

Pain relieved by sitting up and leaning forward

54%

(80/148)

3

High-pitched diastolic murmur

15%

(22/148)

4

Fixed and split S2

7%

(10/148)

5

Mid-systolic click

15%

(22/148)

M 2 E

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