1. Acute Pericarditis Emory Family Medicine
Susan Schayes M.D.
Assistant Professor-CT
Family Medicine, Emory University School of Medicine
IAFP 2002

2. The Pericardium
A fibroelastic sac composed of visceral and parietal layers
Both these layers are separated by a pericardial cavity.
The cavity normally contains 15 to 50 ml of straw-colored fluid.
Visceral layer is in contact with the epicardium (ST elevation)

3. The Clinical problem
Can be an isolated entity or part of a systemic disease
0.1% of all hospitalized patients
5% of ER visits for chest pain without an MI

4. Etiology-Acute Pericarditis
Infectious
Viral : Coxsackie, Echo, EBV, Influenza, HIV
Bacterial: TB, staph, hemophilus, pneumococcal, salmonella
Fungal/other: histo/blasto/coccidio, rickettsial
Rheumatologic
SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, Scleroderma, PAN
Neoplastic
Primary: angiosarcoma, mesothelioma
Metastatic: breast, lung, lymphoma, melanoma, leukemia
Immunologic
Celiac sprue, Inflammatory Bowel Disease
Drug
Hydralazine, Procainamide
Other
MI, Dressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection
Uremic, Post Radiation
IDIOPATHIC

5. Other Pearls
Viral and Autoimmune causes constitute > 50% of cases of acute pericarditis
Pericardial disease is the most frequent cardiovascular manifestation of AIDS
The typical diffuse ST elevation is not seen in uremic pericarditis,in which there is fibrin deposition in the parietal layer but no epicardial inflammation.

6. Clinical Presentation
Chest pain
Pericardial friction rub
Diffuse ST segment elevation on EKG
Pericardial effusion
Presence of at least two of the above features is necessary to make the diagnosis

7. Chest Pain Retrosternal in location Sudden in onset
Pleuritic and sharp in nature
Exacerbated by inspiration
Worsens when supine and improves upon sitting upright or leaning forward.
Can often radiate to the neck, arms, or left shoulder.
Radiation to one or both trapezius muscle ridges, suggests a probable pericarditis (phrenic nerve traverses the pericardium)

8. Pericardial Friction Rub
Present in 85% of cases of pericarditis
Highly specific with a variable sensitivity
A high-pitched scratchy or squeaky sound best heard with the diaphragm at the LSB with the patient leaning forward.
Corresponds temporally to the movement of heart within the pericardial sac.
Has 3 components, which correspond to atrial systole, ventricular systole, and early diastole.
Pericardial friction rub is audible throughout the respiratory cycle, whereas the pleural rub disappears when respirations are on hold.

9. EKG in Pericarditis
Widespread upward concave ST-segment elevation and PR-segment depression
If the ratio of ST-segment elevation to T-wave amplitude in V6 > 0.24, acute pericarditis is almost always present.
The EKG changes have 4 phases during the course of illness

11. EKG Stages Stage I Stage II Stage III Stage IV
first few days  2 weeks
ST elevation, PR depression
up to 50% of pt with symptoms / rub do NOT have or evolve into stage I
Stage II
last days  weeks
Normalization of ST and PR segments
ST returns to baseline, flat T waves
Stage III
after 2-3 weeks, lasts several weeks
Widespread T wave inversion
Stage IV
lasts up to several months
gradual resolution of T wave changes

12. Acute pericarditis – Stage I

13. Pericarditis-Stage II
60 y/o man with acute pericarditis on presentation and after 1 month of resolution of symptoms

14. Pericarditis-Stage III
T wave inversions

15. Differential Diagnoses
Clinical
Myocardial Infarction
Myocarditis
Pulmonary embolism
Pneumothorax
Pneumopericardium
Musculoskeletal
EKG (ST elev)
AMI
Early Repolarization
Myocarditis
Hyperkalemia
Ventricular Aneurysm
Normal Variant

17. Pericarditis vs Early Repolarization
Acute Pericarditis
Early Repolarization
Sex
Either
Usually Male
Age
Any
Usually < 40
PR segment dev
Common
Uncommon
T waves
nl, blunt
tall, peaked
J-ST / T ampl
> 25%
<25%
Tallest precordial R
Usually V5
Usually V4

18. Early Repolarization
J point and ST segment elevation is most prominent in V4 to V6.
The ST segment maintains its normal configuration and is slightly concave

19. Pericarditis vs AMI Pericarditis MI ST segment
Diffuse,concave elevation in all leads except aVR+ V6 w/o reciprocal changes
Height Not > 5mm
Localized, convex, with reciprocal changes in infarct
Height may be > 5 mm
PR depression
Frequent
Almost never
Q waves
Not usual, unless with infarct
Common with q wave infarct
T waves
Inverted after J returns to baseline
T inversions and ST ↑ are not seen simultaneously on the same EKG
Inverted while ST still elevated
T inversions and ST ↑ can be seen simultaneously on the same EKG
Arrhythmias
Rare
Conduction disturbances
frequent

20. Acute Anterior MI

21. Laboratory testing Laboratory abnormalities
CBC – very high WBC (purulent pericarditis)
↑ESR
Chem-7 (uremic etiology)
↑CRP
HIV in selected cases
ANA
Rheumatoid factor
Blood cultures if febrile
Viral cultures and antibody testing not indicated

22. Cardiac Isoenzymes - ? helpful
MB fraction of CK and Troponin I are modestly elevated
The rise in TnI is related to the extent of myocardial inflammation.
Features associated with a rise in Tn I are younger age,male gender,presence of effusion and a recent infection
Enzyme rise is transient,resolving within the first week, persistent ↑ suggest myopericarditis
Not reliable to differentiate MI vs pericarditis
Two studies that included 187 patients with idiopathic pericarditis ,TnI was detectable in 32-49% and in 8-22% it was >1.5 mcg/ml
Another 2 year ER based study-
Out of 14 pts with 2/3 findings (typical CP, rub, and ECG changes)
71% had elevated Tn I with negative CAD workup

23. Other Studies Tuberculin skin testing Echocardiogram Chest X-ray
Normal unless there is an effusion
Presence of effusion supports the diagnosis, but absence does not exclude it.
The ACC/AHA/ASE all recommend to obtain an echo in any suspected pericardial disease
Chest X-ray
Recommended in all cases
Typically normal
Enlarged cardiac silhouette in effusion (with clear lung fields)

24. Need for hospitalization
Many physicians tend to admit them, but this may not be necessary.
Uncomplicated acute pericarditis can undergo initial evaluation in a same day hospital facility or clinic, with an outpatient follow-up
Features of high risk include:
Subacute symptoms (eg, developing over several days or weeks)
High fever (>38ºC [100.4ºF]) and leukocytosis
Evidence suggesting cardiac tamponade
A large pericardial effusion
Immunosuppressed state
A history of oral anticoagulant therapy
Acute trauma
Failure to respond within seven days to NSAID therapy, a generous allocation of time
Elevated cardiac troponin, suggestive of myopericarditis

25. Complications Pericardial Effusion/ Tamponade
Constrictive Pericarditis
can be “transient” – 10% may have transient within 1st month, resolves by 3 months
Recurrent Pericarditis (15-32%)
Recurrent sx after the initiating event is no longer active
Most likely an autoimmune etiology
Rx : NSAIDS/ Colchicine +/- steroids

26. Treatment Goals of acute therapy:
Relieve Pain
Treat the inflammation
Prevent Cardiac tamponade
Most viral infections are self-limited
Treat the underlying disease process
Drain purulent effusions
Symptomatic therapy
None of the treatments unfortunately, have not been proven to prevent the complications.

27. NSAIDs
May require weeks to months of treatment with high doses of NSAIDs
The choice is usually empiric, based on the physician’s familiarity with the agent and/or its availability.
Rapidly titrate the dose within 1–2 days to achieve maximum symptomatic relief
Evaluate for a response within 1–2 wks,Sx usually subside in a week.
If adequate clinical response,continue NSAIDs for 1 wk after complete resolution of Sx and then taper in 2–3 days.

28. Preferred in patients with CAD Ibuprofen
NSAIDs
Aspirin
2-6 gm daily650mg Q3-4 hrs
Preferred in patients with CAD
Ibuprofen
mg daily mg q 6-8 hrs
above average response rate and has a very good side effect profile
Indomethacin
mg daily
Try to avoid, unless absolutely needed as it can ↓ coronary blood flow.
Nonsteroidal Anti-inflammatory Drugs in the Treatment of Pericarditis: Clinical Review
SCHIFFERDECKER, BRANISLAV MD; SPODICK, DAVID H. MD, DSc
Cardiology Review ; Volume 11(4), July/August 2003, pp

29. Colchicine A prospective, randomized, open-label design was used.
120 patients with a first episode of acute pericarditis were randomly assigned to
conventional treatment with aspirin (group I) or
conventional treatment plus colchicine 1.0 to 2.0 mg for the first day and then 0.5 to 1.0 mg/d for 3 months (group II).
Colchicine significantly reduced the recurrence rate (10.7% vs 32.3%; P=0.004;) and presence of symptoms at 72 hours (11.7% vs 36.7%; P=0.003).
Based upon this, addition of it to the Rx regimen for an initial episode of acute pericarditis is an option for physicians.
Colchicine in Addition to Conventional Therapy for Acute Pericarditis
Results of the COlchicine for acute PEricarditis (COPE) Trial
Circulation. 2005;112: /CIRCULATIONAHA eeeeew

30. Steroids In patients refractory to NSAIDs and colchicine
Steroid therapy with initial episode is more likely associated with recurrent episodes.
Evidence available argues against the routine administration of corticosteroids during a first episode of acute pericarditis
Specific conditions that will benefit:
Acute pericarditis due to connective tissue diseases
Auto-immune pericarditis
Uremic pericarditis

31. Myocardial Infarction-Associated Pericarditis
Early post MI pericarditis is a consequence of transmural infarction.
Aspirin is the drug of choice in this setting. (650 mg Q4h)
Late MI associated pericarditis (Dressler syndrome), occurs days to months after infarction,
Autoimmune in etiology.
NSAIDs are the treatment of choice.
Colchicine seems to be the most effective if NSAIDs fail
Corticosteroids seem to provide symptomatic benefit but do not prevent recurrence.
Pericardiectomy is only rarely curative

32. Summary Etiology of Acute Pericarditis
Clinical Presentation and EKG findings
Differential Diagnosis
Evaluation
Treatment