1. Emily O. Jenkins M.D. AM Report 7.13.09
ACUTE PERICARDITIS
Emily O. Jenkins M.D.
AM Report

2. Incidence Exact incidence and prevalence are unknown
Diagnosed in 0.1% of hospitalized patients and 5% of patients admitted for non-acute MI chest pain
Observational study: 27.7 cases/100,000 population/year

3. Etiology: Can be Tricky. . .
Standard diagnostic evaluations are oftentimes relatively low yield
One series elucidated a cause in only 16% of patients
Leading possibilities:
Neoplasia
Tuberculosis
Non-tuberculous infection
Rheumatic disease

5. Initial clinical and echocardiographic evaluation of patients with suspected acute pericarditis

6. Diagnostic Criteria
Chest pain: anterior chest, sudden onset, pleuritic; may decrease in intensity when leans forward, may radiate to one or both trapezius ridges
Pericardial friction rub: most specific, heard best at LSB
EKG changes: new widespread ST elevation or PR depression
Pericardial effusion: absence of does not exclude diagnosis of pericarditis
Supporting signs/symptoms:
Elevated ESR, CRP
Fever
leukocytosis

7. EKG
Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment elevations seen best here in
leads II, III, aVF, and V2 to V6. There is also subtle PR segment deviation (positive in aVR, negative
in most other leads). ST segment elevation is due to a ventricular current of injury associated with epicardial
inflammation; similarly, the PR segment changes are due to an atrial current of injury which, in pericarditis,
typically displaces the PR segment upward in lead aVR and downward in most other leads.

8. Pericardial Effusion
Cardiomegaly due to a massive pericardial effusion. At least 200 mL of pericardial fluid must accumulate before the cardiac silhouette enlarges.

9. Tests EKG CXR PPD ANA HIV Blood cultures
Urgent echocardiogram if evidence of pericardial effusion
Not necessary:
Viral studies b/c yield is low and management is not altered

10. Treatment
NSAIDs + PPI
Aspirin (2-5 g/day)
Ibuprofen ( mg q6-8H)*
Ketorolac
Theoretical concern that anti-platelet agents promote development of hemorrhagic pericardial effusion has not been substantiated
Colchicine (0.5-1 mg/day) : may prevent recurrence
Glucocorticoids (prednisone 1 mg/kg/day): ? increased rate of complications. Should be restricted to:
Acute pericarditis due to connective tissue disease
Autoreactive (immune-mediated) pericarditis
Uremic pericarditis
*NSAID of choice unless associated with acute MI, where all non-ASA NSAIDs should be avoided

11. Prognosis for acute idiopathic pericarditis
Good long-term prognosis
Cardiac tamponade is rare, but up to 70% in cases with specific etiologies (eg. Neoplastic, tuberculous, purulent)
Constrictive pericarditis occurs in about 1% of patients
15-30% of patients not treated with colchicine develop either recurrent or incessant disease

12. Recurrent Pericarditis
Exact recurrence rate unknown
Most cases considered to be autoimmune
Risk Factors:
Lack of response to aspirin or other NSAID
Glucocorticoid therapy
Inappropriate pericardiotomy
Creation of a pericardial window
For some patients, symptoms can only be controlled with steroidal therapy

13. Autoreactive Pericarditis: diagnostic criteria
Pericardial fluid revealing >5000/mm3 mononuclear cells or antisarcolemmal antibodies
Inflammation in epicardial/endomyocardial biopsies by >14 cells/mm2
Exclusion of active viral infection both in pericardial effusion and endocardial/epicardial biopsies
Exclusion of tuberculosis, borrelia burgdorferi, chlamydia pneumoniae and other bacterial infection
Absence of neoplastic infiltration in effusion and biopsy samples
Exclusion of systemic, metabolic disorders and uremia

14. Treatment Aspirin NSAIDs
Colchicine: can reduce or eliminate need for glucocorticoids
Glucocorticoids: should be avoided unless required to treat patients who fail NSAID and colchicine therapy
Many believe that prednisone may perpetuate recurrences
Intrapericardial glucocorticoid therapy: sx improvement and prevention of recurrence in 90% of patients at 3 months and 84% at one year
Other immunosuppression
Azothoprine ( mg/day)
Cyclophosphamide
Mycophenolate: anecdotal evidence only
Methotrexate: limited data
IVIG: limited data
Pericardiectomy: To avoid poor wound healing, recommended to be off prednisone for one year. Reserved for the following cases:
If >1 recurrence is accompanied by tamponade
If recurrence is principally manifested by persistent pain despite an intensive medical trial and evidence of serious glucocorticoid toxicity