History

Fact Explanation
Sudden onset chest pain Chest pain found in pericarditis is sudden in onset, pleuritic type and substernal or left precordial in location. It may radiate to the trapezius ridge, neck, arms, or jaw. The pain is relieved by leaning forward and is made worse by lying supine. [1,2]
Fever, malaise, and myalgia On going inflammation with release of cytokines responsible for these symptoms.[1,2]
Shortness of breath Will be prominent in cardiac tamponade.[1,2]
History of predisposing disease condition Several disease conditions act as predisposing factors to develop acute pericarditis. Diseases related to heart and great vessels are acute myocardial infarction, aortic dissection, cardiac procedures such as catheterization, pacemaker placement, ablation, chest trauma and postpericardiotomy. Other systemic disease conditions are renal failure, malignancies such as breast cancer, lung cancer, Hodgkin's disease, leukemia, radiation therapy (usually for breast or lung cancer) and autoimmune disorders.[1]
History of viral infection Viruses known to cause pericarditis are coxsackievirus A and B, hepatitis viruses, human immunodeficiency virus, influenza, measles virus, mumps virus and varicella virus.[1]
Drug history Some drugs known to cause acute pericarditis such as dantrolene, doxorubicin, hydralazine, isoniazid, penicillin, phenytoin, procainamide and rifampin.[1]
History of AIDS (Acquired Immune Deficiency Syndrome) The most common cardiovascular manifestation of AIDS is pericardial disease. The incidence of bacterial pericarditis has increased among patients with AIDS. They also at high risk for tuberculous and fungal pericarditis.[1]
References
  1. LESLIE E. TINGLE, DANIEL MOLINA, CHARLES W. CALVERT. Acute Pericarditis. Am Fam Physician.[online] 2007 Nov 15;76(10):1509-1514. viewed on 28.05.2014 Available from: http://www.aafp.org/afp/2007/1115/p1509.html
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 30 May 2014] Available from: doi:10.1016/j.ehj.2004.02.002

Examination

Fact Explanation
Pericardial friction rub Inflammation of the pericardium is called pericarditis. Pericardial rub occurs with the movement of the heart against the pericardial sac during atrial systole, ventricular systole, and rapid ventricular filling representing the 3 phases of pericardial rub respectively. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. It can be mono, bi or triphasic and is best auscultated with the diaphragm of the stethoscope along the left sternal border in end expiration with the patient sitting up and leaning forward.[1,2]
Tachycardia Heart rate is usually rapid and regular. Tachycardia also found in cardiac tamponade which needs immediate attention.[1,2]
Tachypnea Usually patients with acute pericarditis have increased respiratory rate but the importance is if the patient is having cardiac tamponade he will definitely tachypneic.[1,2]
Hypotension, jugular venous distention, pulsus paradoxus Appears with the development of cardiac tamponade.[1,2]
Muffled heart sounds Pericardial effusion, cardiac tamponade will disrupt the sound transmission giving rise to muffled heart sounds.[1,2]
Increased body temperature Patient may be febrile.[1,2]
Area of stony dullness in the thorax Acute pericarditis can be associated with pleural effusions.[1,2]
References
  1. LESLIE E. TINGLE, DANIEL MOLINA, CHARLES W. CALVERT. Acute Pericarditis. Am Fam Physician.[online] 2007 Nov 15;76(10):1509-1514. viewed on 28.05.2014 Available from: http://www.aafp.org/afp/2007/1115/p1509.html
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 30 May 2014] Available from: doi:10.1016/j.ehj.2004.02.002

Differential Diagnoses

Fact Explanation
Acute coronary syndromes Myocardial ischemic pain describes as acute onset, tightening type central chest pain radiating to the arms, jaw and also associated with autonomic symptoms such as sweating, nausea. There is no pericardial frictional rub as in acute pericarditis unless it has got complicated. [1,2]
Pulmonary embolism Most of the time patient will have a known risk factor such as pregnancy, deep vein thrombosis, thrombophilic condition..etc. D-dimer levels will be high and pulmonary angiogrm will show the embolus.[1,2]
Aortic Dissection Chest pain will be associated with a back pain and patient will be hemodynamically unstable.[2]
Acute gastritis/Gastro-esophageal reflux diseas(GERD) Patient may known to have gastritis/GERD and will describe burning type of pain in the lower sternal, epigastric region with acid regurgitation and a sour or bitter taste in the mouth. ECG will be normal.[2]
Chest wall pain Chest wall pain is mainly a stinging type, localized pain with no radiation and increased with respiration and chest wall movements. Also pain can be reproduced by palpation.[2]
Pneumonia Patient will have pleuritic type chest pain due to associated pleurisy and other prominent features are fever, productive cough and general ill health. Examination of the lung fields will reveal areas of consolidation. [2]
References
  1. LESLIE E. TINGLE, DANIEL MOLINA, CHARLES W. CALVERT. Acute Pericarditis. Am Fam Physician.[online] 2007 Nov 15;76(10):1509-1514. [viewed on 28.05.2014] Available from: http://www.aafp.org/afp/2007/1115/p1509.html
  2. MCCONAGHY JR, OZA RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician [online] 2013 Feb 1, 87(3):177-82 [viewed 30 May 2014] Available from: http://www.aafp.org/afp/2013/0201/p177.html

Investigations - for Diagnosis

Fact Explanation
ECG(Electrocardiogram) There are 4 ECG stages of pericarditis. They are: 1) diffuse ST elevation and/or PR depression, 2) normalization of ST- and PR-segments, 3) diffuse T-wave inversions with isoelectric ST-segments, and 4) normalization of the ECG. Superficial myocardial inflammation is found out as the cause for these ECG changes. No reciprocal changes or Q waves are found in the 12-lead ECG during acute pericarditis, which is an important feature in distinguishing acute pericarditis from acute MI. The most reliable differential finding in the ECG is the ratio of the magnitude of the ST-segment elevation to the T-wave amplitude in the V6 lead; acute pericarditis is more likely when the ratio is greater than 0.25.[1,2]
Echocardiography Transthoracic echocardiography is often recommended. This help confirming the diagnosis of acute pericarditis and also to detect and exclude cardiac tamponade, pericardial effusion and underlying myocardial disease. If there are findings suggestive of pericardial effusion with clinical evidence of pericarditis, the diagnosis of acute pericarditis is confirmed. Echocardiographic findings of cardiac tamponade are diastolic chamber collapse of the right atrium, right ventricle, or both.[1,2]
C-reactive protein, erythrocyte sedimentation rate and leukocyte count All are elevated as acute pericarditis is often associated with elevated markers of acute inflammation.[1]
Cardiac enzymes - Creatine kinase(MB isoenzyme) and cardiac troponins These are markers of myocardial injury and are often elevated in acute pericarditis due to epicardial inflammation rather than myocardial necrosis.[1,2]
Chest radiography As a baseline, simple, readily available investigation this should be done. Additionally lung fields also can be observed.[1]
Computed tomography and magnetic resonance imaging Useful if the initial investigations for pericarditis is inconclusive.[1]
Special investigations - Antinuclear antibodies, Rheumatoid factor, Mycobacterial studies Should be done to find the cause in whom pericarditis does not improve within one week.[1]
Thoracentesis and pleural fluid analysis, Pericardiocentesis If the patient also has a pleural effusion, aspiration/drainage of that fluid can be done. The pleural fluid analysis includes adenosine deaminase, cytology, and mycobacteria. Pericardiocentesis is only indicated diagnosticaly when purulent pericarditis is suspected.[1]
Subxiphoid pericardial drainage and biopsy with histology and cultures Recommended only if pericardiocentesis is failed or tamponade recurs.[1]
References
  1. LESLIE E. TINGLE, DANIEL MOLINA, CHARLES W. CALVERT. Acute Pericarditis. Am Fam Physician.[online] 2007 Nov 15;76(10):1509-1514. [viewed on 28.05.2014] Available from: http://www.aafp.org/afp/2007/1115/p1509.html
  2. MASEK KP, LEVIS JT. ECG Diagnosis: Acute Pericarditis Perm J [online] 2013, 17(4):e146 [viewed 28 May 2014] Available from: doi:10.7812/TPP/13-044

Management - Specific Treatments

Fact Explanation
Outpatient management Generally most episodes of acute pericarditis are uncomplicated and self limiting. Those uncomplicated patients can be managed as out patients.[1]
Hospitalization Required to find out the etiology and observe for complications as well as the effect of treatment. Indications for hospitalization are 1) Patients on anticoagulation therapy 2) Whose body temperature greater than 100.4° F (38° C) 3) Where there is echocardiographic findings of a large pericardial effusion 4) Clinical evidence of cardiac tamponade ( hypotension and neck vein distention) 5) History of trauma and compromised immune system 6) Myopericarditis 7) Elevated Troponin I levels.[1,2]
Nonsteroidal anti-inflammatory drug (NSAIDs) therapy To relieve chest pain, fever, and pericardial friction rub. Aspirin (up to 800 mg 6 hourly) or ibuprofen (300-800 mg 6 hourly) for days or weeks, best until the effusion has resolved. Ibuprofen is the choice of drug as it has less side-effects, favorable impact on the coronary flow, and the large dose range.[1,2]
Colchicine (0.5 mg bid) Can be used as an adjunct to NSAIDs therapy in patients with acute viral or idiopathic pericarditis. It is known to relieve symptoms quickly and also reduce recurrences.[1,2]
Monitor, detect early and manage complications Complications are pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Patients should be monitored for these complications and treat accordingly.[1]
Pericardiocentesis Indicated in cardiac tamponade (therapeutically) and suspected purulent pericarditis (diagnostically).[1]
Corticosteroids Even though corticosteroids beneficial in refractory acute pericarditis ( associated with connective tissue diseases, auto-reactive or uremic pericarditis), not recommended to use as the sole therapy in patients with acute or idiopathic pericarditis. Intrapericardial application avoids systemic side effects and is highly effective. [1,2]
References
  1. LESLIE E. TINGLE, DANIEL MOLINA, CHARLES W. CALVERT. Acute Pericarditis. Am Fam Physician.[online] 2007 Nov 15;76(10):1509-1514. viewed on 28.05.2014 Available from: http://www.aafp.org/afp/2007/1115/p1509.html
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 30 May 2014] Available from: doi:10.1016/j.ehj.2004.02.002