Dr. M. A. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin

Causes of pericarditis include the following:  Idiopathic causes  Infectious conditions, such as viral, bacterial, and tuberculous infections  Inflammatory disorders, such as RA, SLE, scleroderma, and rheumatic fever  Metabolic disorders, such as renal failure, hypothyroidism, and hypercholesterolemia  Cardiovascular disorders, such as acute MI, Dressler syndrome, and aortic dissection  Miscellaneous causes, such as iatrogenic, neoplasms, drugs, irradiation, cardiovascular procedures, and trauma Symptoms of pericarditis can be described as:  Sharp and stabbing pain (caused by the heart rubbing against the pericardium)  May increase with coughing, swallowing, deep breathing or lying flat  Can be relieved by sitting up and leaning forward  Patient may need to bend over or hold to chest to breathe more comfortably  Other symptoms include:  Pain in the back, neck or left shoulder  Difficulty breathing when lying down  A dry cough  Anxiety or fatigue Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial ECG changes

Acute vs. chronic  Depending on the time of presentation and duration, pericarditis is divided into "acute" and "chronic" forms.  Acute pericarditis is more common than chronic pericarditis  Chronic pericarditis however is less common, a form of which is constrictive pericarditis. Clinically:  Acute (<6 weeks)  Subacute (6 weeks to 6 months)  Chronic (>6 months) Pericarditis can be classified according to the composition of the fluid  Types of pericarditis include the following:  serous  purulent  fibrinous  caseous  hemorrhagic Classification

Characteristi c/ Parameter Pericarditis Myocardial infarction Pain description Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain Crushing, pressure-like, heavy pain. Described as "elephant on the chest." Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw, or the left arm, or does not radiate ExertionDoes not change the painCan increase the pain Position Pain is worse in the supine position or upon inspiration (breathing in) Not positional Onset/duratio n Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER Clinical presentation

Diagnosis Initial evaluation includes a clinical history and physical examination, ECG, echocardiography, chest radiography, and lab studies 1.ECG can be diagnostic in acute pericarditis and typically shows ST elevation in all leads 2.Echocardiography is particularly helpful if pericardial effusion is suspected on clinical or radiographic grounds, the illness lasts longer than 1 week, or myocarditis or purulent pericarditis is suspected 3.A chest radiograph is only helpful for diagnosis in patients with effusions >250mL. Patients with small effusions (less than a few hundred milliliters) may present with a normal cardiac silhouette 4.Lab tests may include CBC; serum electrolyte, blood urea nitrogen (BUN), and creatinine levels; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels; and cardiac biomarker measurements, lactate dehydrogenase (LDH), and serum glutamic-oxaloacetic transaminase (SGOT; AST) levels.

ECG changes in acute pericarditis

Pericardial effusion Echocardiogr am

Diagnostic considerations: 1.costochondritis, or other causes of noncardiac chest pain 2.Pericarditis may occur after renal transplantation, which may be related to uremia or infections (eg, cytomegalovirus CMV). 3. Liver disease has been noted in asymptomatic constrictive pericarditis. 4.Small asymptomatic pericardial effusions in patients with acquired immunodeficiency syndrome (AIDS) may not require diagnostic evaluation 5.Large symptomatic pericardial effusions should be investigated, because two thirds of such effusions are potentially infections or neoplasms. 6.Tuberculous pericarditis can also occur 7.Tension pneumothorax may mimic cardiac tamponade 8.Differentiating pericarditis from acute MI

 Angina Pectoris  Aortic Dissection  Aortic Stenosis  Coronary Artery Vasospasm  Esophageal Rupture  Esophageal Spasm  Esophagitis  Gastritis, Acute  Gastroesophageal Reflux Disease  Myocardial Infarction  Myocardial Ischemia  Peptic Ulcer Disease  Pulmonary Embolism Differential diagnosis

 Oxygen and a cardiac monitor should be provided.  Rule out other life- threatening causes of chest pain: ◦ Myocardial infarction (MI) or ◦ Aortic dissection.  Evaluate for evidence of hemodynamic instability  Consider whether further management is safe to continue on an outpatient basis  Avoid NSAIDs and corticosteroids in acute MI pericarditis, because they may interfere with ventricular healing, remodeling, or both Poor prognostic factors:  Myopericarditis  Severe pericardial effusion  Cardiac tamponade  Patients may require transfer to a hospital setting in which hemodialysis and cardiothoracic surgery are available  Pericardiocentesis: People with effusions larger than 250 mL, effusions in which size increases  Pericardiectomy is the most effective surgical procedure for managing large effusions Management