Pericarditis Moira Nester RN, BSN

Background Pericardial Cavity Fibrous Layer Myocardium Parietal Pericardium Endocardium Visceral Pericardium

Pericarditis https://www.nlm.nih.gov/medlineplus/ency/article/000182.htm

Etiology 80 – 90% are idiopathic or viral Bacterial, tuberculous, HIV, fungal, amebic, toxoplasmosis Collagen-vascular disease Neoplasm Drug-induced Acute myocardial infarction and post-MI (Dressler’s syndrome) Trauma (postpericardiotomy, postpacemaker lead placement, postcatheter ablation, CPR) Metabolic (Hypothyroidism, uremia) Leakage of aortic aneurysm into pericardial sac Radiation Therapy Collagen vascular disease (SLE, RA, scleroderma, vasculitis, dermatomyositis) Drug induced: procainadmide, hydralazine, phenytoin, isoniazid, rifampin, doxorubicin, mesalamine

Presentation Sharp and sudden substernal chest pain May radiate to neck, shoulders, back, or arms Pain varies with respiration Worse when lying down Relieved by sitting up and leaning forward Fever, cough, dyspnea, palpitations, night sweats, weight loss, dysphagia Acute pericarditis can present in a variety of ways, depending on the underlying cause.

History PMH/PSH Medications Family History Malignancy, autoimmune disorders, uremia, recent MI, prior cardiac surgery Medications procainadmide, hydralazine, phenytoin, isoniazid, rifampin, doxorubicin, mesalamine Family History Autoimmune disorders When getting a history from the patient, it is important to determine whether or not there are any disorders that are known to involve the pericardium (UpToDate, 2015).

Review of Systems General – Fever, chills, fatigue, night sweats, weight loss Skin – Pallor, clamminess HEENT – Pain with swallowing Lungs – Tachypnea, Dyspnea, SOB, Pain on inspiration C/V – Chest Pain, Palpitations, dizziness, syncope GI – Abdominal pain GU – Difficulty Musculoskeletal – Joint pain Neurologic – Anxiety, fatigue, altered mental status

Physical Examination Heart: S/Sx of Effusion & Tamponade Pericardial Friction Rub Diminished apical pulse S/Sx of Effusion & Tamponade Dyspnea Tachycardia Fluid retention, ascites Hepatomegaly Pallor, clammy skin Hypotension If there is a significant pericardial effusion, cardiac tamponade can occur, resulting in an inability to pump fluid out of the heart. It then backs up leading to fluid retention, ascites, and hepatomegaly.

Diagnosis TWO of the following: Sharp, pleuritic chest pain, improved by sitting up and leaning forward Pericardial friction rub Suggestive changes on the ECG New or worsening pericardial effusion (UpToDate, 2015)

Pericardial Friction Rub Superficial scratchy/squeaky quality Generated by friction between layers of the pericardium Loudest on left sternal border (UpToDate, 2015)

Suggestive ECG changes Diffuse upsloping of the ST segment elevations. (UpToDate, 2015)

Diagnostic Tests Blood work: Echocardiogram Chest radiography White blood cell count, C-reactive Protein, ANA, & Erythrocyte Sedimentation Rate are markers of inflammation. Echocardiogram Typically normal, but an associated pericardial effusion can confirm the diagnosis of pericarditis. Chest radiography Also typically normal – watch for a pericardial effusion. Electrocardiography Diffuse upsloping of ST segment elevations

Differential Diagnosis Angina Pectoris/Myocardial Ischemia Pulmonary causes: Embolism, infarction, pneumothorax Dissecting aneurysm GI causes (GERD, choelcystitis)

Treatment Goal: Target underlying cause (if there is one) Most patients can be treated with medical therapy on an outpatient basis: NSAIDS Colchicine Glucocorticoids if NSAIDS/Colchicine ineffective A large pericardial effusion: Requires pericardial drainage and/or pericardial window Activity Restrictions Strenuous activity may trigger recurrence of symptoms Avoid until symptom resolution

Outcomes Good long-term prognosis >80% of cases follow a benign course Complete resolution of pain and other signs and symptoms during the initial 3 week of therapy occurs in 70% to 90% of cases Recurrence in 10% to 15% of patients within the initial 12 mo. Cardiac tamponade rarely occurs in patients with acute idiopathic pericarditis or viral pericarditis. More common in patients with specific underlying etiology such as malignancy, tuberculosis, or purulent pericarditis. Patients with acute idiopathic or viral pericarditis have a good long-term prognosis.

Journal Article Risk of constrictive pericarditis after acute pericarditis By Imazio et. Al Found that patients who have a bacterial etiology in acute pericarditis are more likely to suffer from the complication of constrictive pericarditis compared to a viral etiology or an underlying patholgy. First prospective study, so more research is needed.

References Cabrera, G., & Schub, T. (2016, June 19). Pericarditis. Retrieved February 23, 2016, from http://search.ebscohost.com.ezaccess.libraries.psu.edu/login.aspx?direct=true& db=nrc&AN=T701154&site=nrc-live Ferri, F. F., & Alvero, R. (2016). Ferri's clinical advisor 2016: 5 books in 1. Philadelphia, Pennsylvania: Elsevier. Imazio, M., Brucato, A., Maestroni, S., Cumetti, D., Belli, R., Trinchero, R., & Adler, Y. (2011). Risk of constrictive pericarditis after acute pericarditis. Circulation, 124(11), 1270-1275. doi:10.1161/CIRCULATIONAHA.111.018580 Pericarditis: MedlinePlus medical encyclopedia. (n.d.). Retrieved February 23, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/000182.htm Pericardium (2014). (4th ed.) Oxford University Press. Post, T. W. (2016). Clinical presentation and diagnostic evaluation of acute pericarditis. In UpToDate. Waltham, MA.