Related Subjects:
| Assessing Breathlessness
| Assessing Chest Pain
| Pericardial Effusion and Tamponade
| Constrictive Pericarditis
| Colchicine
ST changes in pericarditis are widespread and typically concave ("saddle-shaped"). There may also be peaked T waves and widespread PR depression.
Management Summary: ECG ST Elevation and PR Depression |
Initial Attack
- First Line: Aspirin or NSAID + Colchicine + exercise restriction
- Second Line: Low-dose steroids (if unable to take Aspirin or NSAID + Colchicine) after excluding infection
Recurrence
- First Line: Aspirin or NSAID + Colchicine + exercise restriction
- Second Line: Low-dose steroids (if unable to take Aspirin or NSAID + Colchicine) after excluding infection
- Third Line: IVIG or Anakinra or Azathioprine
- Fourth Line: Pericardiectomy
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Epidemiology
- Pericarditis accounts for 5% of emergency room admissions for chest pain.
- 5% of patients with pericarditis develop complications such as tamponade or constrictive pericarditis.
Clinical Presentation
- Fever, sweats, malaise, myalgia
- Pleuritic chest pain worsened by inspiration or cough
- Pain is positional—improves when sitting up and leaning forward.
- Friction rub: audible with three components—atrial systole, ventricular systole, and diastole.
- Possible squeaky sound at the left sternal border
- Distant heart sounds suggest a pericardial effusion.
Assess for tamponade: look for distended neck veins, pulsus paradoxus (>10–15 mmHg by blood pressure cuff), and hypotension.
Differential Diagnosis for Chest Pain
- Acute coronary syndrome, myocarditis, aortic dissection
- Pneumonia, pneumonitis, pulmonary embolism
- Gastroesophageal reflux disease (GORD), oesophageal disease
- Musculoskeletal causes
Causes of Pericarditis
- Idiopathic/Post-viral
- Myocardial infarction (MI) or post-MI (Dressler's syndrome)
- Post-pericardiotomy syndrome
- Infectious: bacterial, viral, fungal, HIV
- Malignancy
- Metabolic causes: uremia, dialysis
- Autoimmune: systemic lupus erythematosus, Dressler's syndrome
- Familial Mediterranean fever
- Trauma/Radiation exposure
- Aortic dissection
- Drugs and congenital conditions
Investigations
- Blood Tests: FBC, U&E, LFT, CRP, ESR
- ECG: Widespread ST-segment elevation and PR depression in most leads. The changes evolve over time:
- Stage 1: Saddle-shaped ST elevation in most leads, PR depression except in aVR (where ST is depressed).
- Stage 2: ST/PR changes resolve.
- Stage 3: Widespread T wave inversion.
- Stage 4: T wave changes resolve.
The differential diagnosis includes STEMI and early repolarization.
- CRP/ESR: Elevated, indicating inflammation or infection.
- CK/Troponin: Elevated levels suggest concurrent myocarditis (myopericarditis).
- CXR: Usually normal, but may show cardiomegaly in cases of effusion.
- Echocardiogram: Up to 60% of cases may show pericardial effusion, though tamponade is rare.
ECG: Generalized Saddle-shaped ST Elevation
Predictors of Worse Prognosis
- Major:
- Fever >38°C
- Elevated CRP
- Subacute onset
- Large pericardial effusion
- Cardiac tamponade
- Lack of response to NSAIDs or Aspirin after 1 week
- Minor:
- Myopericarditis
- Immunosuppression
- Trauma
- Oral anticoagulant use
Management
- Most cases of idiopathic or viral pericarditis are self-limiting and resolve in 2-6 weeks. Severe complications are rare.
- Cardiac tamponade is uncommon, occurring mainly early in the disease course.
- Patients with myopericarditis generally have a good prognosis with no evolution to heart failure.
- Exercise Restriction: Athletes are advised to resume competitive sports only after symptoms have resolved and diagnostic tests (e.g., CRP, ECG, echocardiogram) have normalized. Some experts recommend waiting 3 months.
- Consider Admission if:
- Non-viral cause
- Fever >38°C
- Effusion >20 mm
- Tamponade
- Trauma
- Immunosuppression
- Anticoagulant use
- NSAIDs: Ibuprofen 400-600 mg TDS for 1-2 weeks with a PPI for gastric protection.
- Colchicine: Used for acute and recurrent pericarditis (1 g/day if >70 kg, 0.5 g/day if <70 kg) for 3 months under specialist review.
- Steroids: Consider for more severe cases or if NSAIDs are contraindicated.
- Infection: Treat with appropriate antibiotics (for bacterial causes), antifungals (for fungal causes), or anti-TB therapy (if tuberculosis is suspected).
- Anticoagulants: Assess the risks and benefits, particularly in patients with pericardial involvement, as there is a risk of bleeding into the pericardial space.
- Neoplasia: Consider chemotherapy for malignancy-related pericarditis.
References