Acute Pericarditis

Related Subjects: | Assessing Breathlessness | Assessing Chest Pain | Pericardial Effusion and Tamponade | Constrictive Pericarditis | Colchicine

❤️ ST changes in pericarditis are typically widespread, concave (“saddle-shaped” ⛰️), with PR depression 📉 and sometimes peaked T waves.

🌍 Epidemiology

• Accounts for ~5% of ED chest pain presentations 🏥.
• ⚠️ ~5% develop complications (tamponade, constriction).

🩺 Clinical Presentation

• Fever 🤒, sweats, malaise, myalgia
• Pleuritic chest pain worsens with inspiration/cough 🫁
• Positional pain: improves when sitting forward 🪑
• Friction rub 🎧 with 3 components (atrial systole, ventricular systole, diastole)
• Squeaky sound at LSB
• Distant heart sounds → pericardial effusion 💧

🚨 Assess for tamponade: raised JVP, pulsus paradoxus (>10–15 mmHg), hypotension.

❓ Differentials for Chest Pain

• ACS (MI) ❤️‍🔥, myocarditis, aortic dissection
• Pneumonia 🌬️, PE 🩸
• GORD/oesophageal pain 🍔🔥
• MSK pain 💪

🧬 Causes

• Idiopathic/Post-viral 🦠
• MI or post-MI (Dressler’s)
• Post-pericardiotomy
• Infections: bacterial, fungal, HIV
• Malignancy 🎗️
• Metabolic: uremia, dialysis
• Autoimmune (e.g. SLE 🦋)
• Familial Mediterranean fever 🌊
• Trauma/Radiation ☢️
• Aortic dissection
• Drugs 💊, congenital conditions

🔎 Investigations

• Bloods: FBC, U&E, CRP/ESR ↑
• ECG: Generalized saddle-shaped ST ↑ + PR depression 📉 Stages: 1️⃣ Widespread concave ST ↑, PR ↓ (except aVR) 2️⃣ ST/PR normalize 3️⃣ T inversion ⬇️ 4️⃣ T waves normalize
• Troponin: ↑ if myopericarditis
• CXR: Often normal, ± cardiomegaly
• Echo: Effusion in ~60%, tamponade rare

📊 Predictors of Worse Prognosis

• Major: Fever >38°C 🌡️, ↑ CRP, subacute onset, large effusion, tamponade 🚑, no response to NSAIDs
• Minor: Myopericarditis, immunosuppression, trauma, anticoagulants

🩺 Management

• 🕒 Usually self-limiting (2–6 weeks).
• Cardiac tamponade rare but dangerous 🚨.
• Myopericarditis: good prognosis, no progression to HF.
• Exercise restriction: Athletes avoid sport until CRP, ECG, echo normalize (often ≥3 months).
• Admit if: Non-viral cause, fever >38°C, effusion >20mm, tamponade, trauma, immunosuppression, anticoagulant use.
• NSAIDs: Ibuprofen 400–600mg TDS + PPI
• Colchicine: 0.5–1mg/day for 3 months
• Steroids: Only if NSAIDs contraindicated.
• Infection: Antibiotics, antifungals, anti-TB as appropriate.
• Neoplastic: Consider chemo/radiotherapy.

📚 References

• 2015 ESC Guidelines on Pericardial Disease

🧑‍⚕️ Case Examples - Acute Pericarditis

• Case 1 (Viral pericarditis): 🦠 A 25-year-old man presents with sharp pleuritic chest pain that improves when sitting forward. ECG shows widespread ST elevation with PR depression. CRP mildly raised, troponin normal. Analysis: Typical post-viral pericarditis - positional pain, pleuritic, and ECG features. Diagnosis: Viral acute pericarditis. Management: NSAIDs + colchicine for 3 months, rest, avoid strenuous exercise; monitor for effusion.
• Case 2 (Post-MI pericarditis - Dressler’s syndrome): ❤️‍🔥 A 60-year-old man, 3 weeks after an anterior STEMI, presents with fever, chest pain worse lying flat, and a pericardial rub on exam. Analysis: Autoimmune reaction post-MI (“Dressler’s syndrome”). Often associated with pericardial effusion. Diagnosis: Post-MI pericarditis. Management: High-dose NSAIDs, colchicine; avoid anticoagulation if large effusion (tamponade risk).
• Case 3 (Uraemic pericarditis): 🧬 A 48-year-old man with stage 5 CKD on dialysis develops chest pain and pericardial rub. Echo shows small pericardial effusion, no tamponade. Analysis: Toxins accumulate in renal failure → inflammation of pericardium. Diagnosis: Uraemic pericarditis. Management: Intensify dialysis, avoid anticoagulation; NSAIDs used cautiously, colchicine possible if tolerated.