Hannah Jones, PGY-1 Pericarditis

Case: 22yo Male with no PMH who presents to the ED c/o chest pain which woke him up in the middle of the night. Referred to the ED for LP a few days prior after presenting to CDM with headache, neck pain and fever. LP: Negative

Case PMH: None PSH: Shoulder surgery (not recent) SH: College student, Athletic, Works in campus health clinic Denies tobacco use. 1 alcoholic beverage/wk. Occasional Marijuana FH: No pertinent history Medications: None Allergies: None ROS: + Diaphoresis, Nausea, SOB, CP, Headache, Neck pain Vitals: T 101.8, BP 117/57, HR 66, R 18, SpO2 100% RA Physical Exam: No abnormal physical exam findings.

Studies ECG: Mild, diffuse ST elevation ECHO: Global hypokinesis, EF 40% Troponin: 4.62 CRP: 95.9 ESR: 12 ANA: Negative Blood Cultures: Negative

Inflammation of the pericardial sac. Acute Pericarditis: Inflammation of the pericardial sac. Myopericarditis: Acute pericarditis + myocardial inflammation

Epidemiology Most common disorder of pericardium Accounts for 5% of patients who present to the ED with non-ischemic chest pain Developed countries: Viral or idiopathic Developing countries: HIV & Tuberculosis Isolated or first presentation of underlying disease

Clinical Presentation Chest Pain: Present in > 95% of cases Sudden onset Sharp & pleuritic or Dull Anterior chest or radiation to shoulders Symptoms of systemic infection Symptoms related to underlying disorder

Exam Pericardial friction rub – Left sternal border -Highly specific for acute pericarditis -Vary in intensity & may come and go - Infection or underlying disease

Diagnostic studies Electrocardiogram – Inflammation of epicardium Diffuse ST elevation, Depression in aVR & V1 -Rarely exceeds 5mm Elevation of PR in aVR – Highly Specific Late: Diffuse T wave inversion after ST segment becomes isoelectric

ECG

Diagnostic studies Chest X-ray -Usually normal. May see enlarged cardiac silhouette if effusion is present Echocardiogram - Often normal in acute setting. May see pericardial effusion. Dysfunction possible in myopericarditis.

Diagnostic Criteria Acute Pericarditis – 2 or more: -Typical chest pain -Friction rub -Characteristic ECG changes -New/worsening pericardial effusion Myopericardits – acute pericarditis + 1 or more: Elevation in serum cardiac biomarkers New or presumed new focal or global left ventricular systolic dysfunction

Labs CBC –Increased WBC count Troponin – elevated in myopericarditis ESR/CRP – supportive…not sensitive or specific Blood Cultures -If fever > 100.4 or signs of sepsis -Additional Testing TB skin test HIV testing ANA (If concern for SLE)

Etiology Idiopathic Infectious -Viral: coxsackievirus, echovirus, Influenza, CMV, HIV -Bacterial: TB, Staphylococcus, Pneumococcus -Fungal: Histoplasmosis (immune competent) Rheumatologic: SLE, RA, polyarteritis, scleroderma Neoplastic -Primary: Mesothelioma -Metastatic: Lung, Breast, Lymphoma

Treatment Treat underlying disorder (If identified) Ibuprofen 600-800 mg TID x 1-2 weeks OR Aspirin 650-1000 mg TID x 1-2 weeks -GI prophylaxis!! PPI AND Colchicine 0.5-0.6 mg BID x 3months

Treatment ICAP Trial -Colchicine in addition to standard anti-inflammatory therapy reduces risk of recurrence by 21% vs. anti-inflammatory treatment alone. -Better remission rates & fewer hospitalizations

Treatment Glucocorticoids generally avoided EXCEPT: Recurrent Refractory to NSAID/ASA + colchicine Contraindication for NSAID/ASA Prednisone 0.25-0.5 mg/kg/day x 2 weeks (gradual taper) + Colchicine

Treatment Close follow-up as outpatient or Hospitalization Monitor CRP Repeat ECHO if associated myocardial dysfunction on presentation No strenuous physical activity/Athletics for 6 months. Return after normalization of lab - NO Toxins!!

Hospitalization For High Risk Features: Fever > 100.4 and leukocytosis Evidence of cardiac tamponade Large pericardial effusion Immunosuppressed Acute Trauma Elevated Troponin (suggests myopericaridtis) Failure to respond to anti-inflammatory therapy in 7 days.

Our Patient: Treated with: 650mg ASA TID & Colchicine 0.6mg BID Troponin decreased to 1.82 by day # 2 Repeat ECHO on day #2 demonstrated improved EF – 50-55% Blood cultures and ID studies Negative Discharged on day #2 with ASA, Colchicine, Lisinopril. Told to avoid Athletics/Toxins. F/U with cardiology in 2 weeks

References Georgia Regents University: Heart sounds. https://itunes.apple.com/us/itunes-u/heart-sounds/id430121352?mt=10. Imazio, M. Clinical presentation and diagnostic evaluation of acute pericarditis. UpToDate 2013 Imazio, M. Treatment of acute pericarditis. UpToDate 2013 Imazio M. Contemporary management of pericardial diseases. Curr Opin Cardiol 2012; 27:308. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med 2013; 369:1522.

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