1. Pericarditis
Moira Nester RN, BSN

2. Background Pericardial Cavity Fibrous Layer Myocardium
Parietal Pericardium
Endocardium
Visceral Pericardium

3. Pericarditis

4. 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

5. 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.

6. 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).

7. 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

8. 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.

9. 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)

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

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

12. 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

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

14. 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

15. 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.

16. 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.

17. References
Cabrera, G., & Schub, T. (2016, June 19). Pericarditis. Retrieved February 23, 2016, from 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), doi: /CIRCULATIONAHA
Pericarditis: MedlinePlus medical encyclopedia. (n.d.). Retrieved February 23, 2016, from
Pericardium (2014). (4th ed.) Oxford University Press.
Post, T. W. (2016). Clinical presentation and diagnostic evaluation of acute pericarditis. In UpToDate. Waltham, MA.