Pericarditis
Introduction
Acute pericarditis, caused by inflammation of the pericardium, manifests as chest
pain, a pericardial friction rub, and has serial electrocardiogram (ECG) abnormalities.
The incidence is 1/1000 hospital admissions. At autopsy, changes of pericarditis appear in
2 to 6 percent of cases. The majority of cases are idiopathic or postviral, but acute
myocardial infarction, uremia, bacterial infection, tuberculosis, collagen-vascular
disease, neoplasm, and trauma must be considered.
Symptoms suggestive
of pericarditis
Pericarditis chest pain occurs in the pericardium with a pleuritic component.
Recumbency increases the pain, which often radiates to the trapezius ridge. Swallowing may
exacerbate pain. Dyspnea results from pleural irritation or, on occasion, accumulation of
a large pericardial effusion. Symptoms typically occur with an ongoing or preceding upper
respiratory infection. Exertion may exacerbate chest pain, but the pleuritic nature and
positional component persist. When pericarditis follows myocardial infarction, ischemic
chest pain precedes. Coexistent symptoms of pneumonitis suggest a bacterial etiology,
especially with high fever. Recurrent fevers, sweats, and weight loss suggest
tuberculosis. Malignant pericarditis is usually metastatic with other clinical evidence of
malignancy. Common primary tumors include lung, breast, melanoma, lymphoma, and leukemia.
Physical exam
findings
Physical examination includes a careful assessment of vital signs with
determination of pulsus paradoxicus. Neck vein distension, distant heart tones, and poor
peripheral perfusion suggest cardiac tamponade, especially with a pulsus paradoxicus of
greater than 10 mm Hg. Lung auscultation may show signs of consolidation. Cardiac
auscultation provides the important, but often evanescent, pericardial friction rub, which
may be of one, two, or three components. The complete blood count (CBC), which is usually
normal, may indicate an infection or leukemia. An erythrocyte sedimentation rate (ESR) is
often elevated; a nonspecific finding. A tuberculin test, PPD (purified protein
derivative), should be applied to patients who have not been previously reactive. The
chest x-ray is usually normal, but may include evidence of pneumonitis, tumor, or
cardiomegaly suggesting pericardial effusion.
Electrocardiogram (ECG)
ECG diagnosis of pericarditis depends on serial changes from a current
injury caused by superficial myocardial inflammation or epicardial injury. Four stages are
described. Stage I occurs with the onset of chest pain. ST segment elevations are concave
upward and usually noted in all leads except AVR and V1. Stage II, seen several days
later, shows return of ST segments to baseline with T flattening. T inversion is seen in
stage III, without loss of R voltage or new Qs. In stage IV, weeks to months later, Ts
revert to normal. Atypical ECG patterns occur in up to 50 percent of patients and prompt
careful consideration of an ischemic etiology, especially with an atypical history or the
absence of a pericardial friction rub.
Differential diagnosis of
pericarditis
Management considerations
In port, patients with acute pericarditis should be admitted to a hospital. In rare
cases, mild illness may be handled as an outpatient with close follow up by an internist.
At sea, patients with a typical history, physical, and ECG findings of postviral or
idiopathic pericarditis may be treated and closely observed in sick bay. Significant
improvement is expected in 1 to 2 days. Dysrhythmias and hemodynamic complications are
rare. Patients should be referred to a specialist upon arrival in port, even if
asymptomatic. They should rest until asymptomatic and should not return to duty until full
evaluation is completed. Patients with atypical presentations, especially if ischemia,
tuberculosis bacterial infection, or suspected tumor, should be expeditiously transferred
to a tertiary care facility. Hemodynamic compromise demands rapid evaluation.
Pericardiocentesis may be required.
Treatment
Acute pericarditis responds well to rest and nonsteroidal
anti-inflammatory treatment. Most physicians prefer ibuprofen, 400-800 mg orally TID or
QID. In mild cases, aspirin may be used, 650 mg PO QID. In the past, indomethacin was
used, but caused more gastric irritation. Prednisone has proven effective in difficult
cases, but is frequently associated with recurrence. Colchicine 0.6 mg BID has been
effective in treating recurrent pericarditis. For a discussion of pericardiocentesis, see
the American Heart Associations Advanced Cardiac Life Support (ACLS) Manual. The
severity of illness, suspected etiology, and firmness of diagnosis dictate the disposition
and urgency of disposition. Ischemia or hemodynamic compromise mandate emergent transfer.
Overt infection similarly requires emergency culture, treatment, and transfer. Suspicion
of malignancy or infection dictates urgent referral. Timely communication with a
specialist provides helpful, case-specific assistance.
Reference
-
Permanyer-Miralda G, Sagrista Sauleda J, and Soler-Soler J. Primary Acute Pericardial
Disease: A Prospective Series of 231 Consecutive Patients. AM J Cardiol 1985; 56 623-630.
Reviewed by CAPT K. F. Strosahl, MC, USN, Cardiology/Computer
Assisted Program of Cardiology Specialty Leader, Cardiovascular Disease
Division, Portsmouth Naval Hospital, Portsmouth, VA (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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