1. Hannah Jones, PGY-1
Pericarditis

2. 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

3. 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.

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

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

6. 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

7. 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

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

9. 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

10. ECG

11. 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.

12. 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

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

14. 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

15. Treatment Treat underlying disorder (If identified)
Ibuprofen mg TID x 1-2 weeks OR
Aspirin mg TID x 1-2 weeks
-GI prophylaxis!! PPI
AND
Colchicine mg BID x 3months

16. 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

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

18. 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!!

19. Hospitalization For High Risk Features:
Fever > 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.

20. 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

21. References
Georgia Regents University: Heart sounds.
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.

22. Questions ?