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Acute Non-Specific Pericarditis R Postgrad Med J: first published as 10.1136/pgmj.43.502.534 on 1 August 1967. Downloaded from Postgrad. med. J. (August 1967) 43, 534-538. CURRENT SURVEY Acute non-specific pericarditis R. G. GOLD * M.B., B.S., M.RA.C.P., M.R.C.P. Senior Registrar, Cardiac Department, Brompton Hospital, London, S.W.3 Incidence neck, to either flank and frequently through to the Acute non-specific pericarditis (acute benign back. Occasionally pain is experienced on swallow- pericarditis; acute idiopathic pericarditis) has been ing (McGuire et al., 1954) and this was the pre- recognized for over 100 years (Christian, 1951). In senting symptom in one of our own patients. Mild 1942 Barnes & Burchell described fourteen cases attacks of premonitory chest pain may occur up to of the condition and since then several series of 4 weeks before the main onset of symptoms cases have been published (Krook, 1954; Scherl, (Martin, 1966). Malaise is very common, and is 1956; Swan, 1960; Martin, 1966; Logue & often severe and accompanied by listlessness and Wendkos, 1948). depression. The latter symptom is especially com- Until recently Swan's (1960) series of fourteen mon in patients suffering multiple relapses or patients was the largest collection of cases in this prolonged attacks, but is only partly related to the country. In 1966 Martin was able to collect most length of the illness and fluctuates markedly from of his nineteen cases within 1 year in a 550-bed day to day with the patient's general condition. hospital. The disease is thus by no means rare and Tachycardia occurs in almost every patient at warrants greater attention than has previously some stage of the illness. It is usually sinus incopyright. been aceorded it, despite its usually benign course. origin and may outlast all other symptoms and signs by several months (Dressler, 1966). James Clinical features (1962) has shown that because of the close prox- Acute non-specific pericarditis can occur at any imity of the sinus node to the epicardium it is age but is most common in the third and fourth usually involved in pericarditis. Sinus tachycardia decades (Bradley, 1964). The sex incidence has in pericarditis thus indicates irritation of the sinus been variously reported as equal (Bradley, 1964), node. Other dysrhythmias, e.g. atrial fibrillation M/F 3 :1 (McGuire, Kotte & Helm, 1954) and (Soffer, 1960), supraventricular and ventricular M/F 8-5 :1 (Martin, 1966). A history of an upper ectopics and tachycardia, and atrial flutter may http://pmj.bmj.com/ respiratory tract infection about 2 weeks before is occur. Pyrexia of more than 100°F is present in common (McGuire et al., 1954). The onset is most patients at the onset of the illness but a few almost always acute and pain the almost universal patients remain afebrile throughout. presenting symptom. The pain is usually severe A pericardial friction rub is probably present in and may be accompanied by shock and hypo- most patients at some stage of the illness. How- tension (Martin, 1966). It may be sharp and stab- ever, it may be extremely transitory and may bing and aggravated by respiration, or dull and disappear completely within a matter of hours or on October 2, 2021 by guest. Protected aching. It is unrelated to exertion though may be be replaced by a pericardial click. Auscultation of prolonged and aggravated by the patient's failure the heart several times a day during the acute to rest. The pain is very often aggravated by rotat- stages is, therefore, advisable to detect it. The ing the trunk (McGuire et al., 1954), by bending behaviour of the pericardial rub is independent of forward at the waist (Bradley, 1964), or in extreme the intensity of pain. The effect of respiration on recumbency and lying on the left side (Friedberg, the intensity of the pericardial rub is very variable 1966). The site of the pain is frequently retro- and occasionally the patient's position is crucial, sternal and if also dull and pressing may result in the rub only being heard, for example, when the a wrong diagnosis of myocardial infarction. It may patient bends forward (Bradley, 1964). The heart radiate to one or both shoulders and arms, to the sounds are otherwise normal apart from being dulled at times by pericardial effusion. *Present address: Shotley Bridge General Hospital, The occurrence of pericardial effusion in acute Shotley Bridge, Co. Durham. non-specific pericarditis is extremely variable, the Postgrad Med J: first published as 10.1136/pgmj.43.502.534 on 1 August 1967. Downloaded from Current survey 535 reported incidence ranging from 20% (Martin, may demonstrate pericardial thickening and loss 1966) to 73% (Bradley, 1964). Pericardial tam- of mobility of the right heart border. At the same ponade should be suspected if there is marked time the right atrial pressure wave form may show elevation of the jugular venous pressure with a the systolic descent characteristic of pericardial systolic descent in the wave form (Gibson, 1960) tamponade or constriction (Gibson, 1960). accompanied by pulsus paradoxus. The presence Pericardiocentesis should be performed as a of a third heart sound does not indicate pericardial therapeutic measure where cardiac tamponade is tamponade or constriction but is a sign of under- suspected and as a means of obtaining fluid for lying myocardial failure (Gibson, 1960). A positive bacteriological, virological and cytological study Kussmaul's sign (elevation of the mean jugular where the diagnosis is in doubt. The pericardial venous pressure on inspiration) is likewise mis- fluid may be serous or, especially when anti- leading and can occur in any situation producing coagulants have been given for a mistaken diag- marked elevation of the jugular venous pressure, nosis of myocardial infarction, blood stained (Liu notably cardiac failure. Pleural effusion and/or & Garcia, 1965). pneumonitis occur not infrequently and produce The electrocardiogram is frequently unreward- the corresponding physical signs in the lungs. ing in acute non-specific pericarditis. It may range from normal to the type of tracing suspicious of Special investigations acute or chronic coronary artery disease (Bradley, Since the diagnosis of acute non-specific peri- 1964). In one of our patients whose illness lasted carditis is largely one of exclusion, special tests 4 months the only electrocardiographic abnor- are as much directed at ruling out other causes of mality was intermittent mild ST segment depres- pericarditis, e.g. bacterial infection, including sion in several leads coinciding with clinical tuberculosis; collagen disease, notably systemic exacerbations of her illness. The classical pattern lupus erythematosus and peri-arteritis nodosa; in pericarditis of raised ST segment, retaining its and infectious mononucleosis, as in confirming the natural concavity, returning within a few days to diagnosis. the isopotential level or becoming depressed with Chest X-ray may be completely normal. Its subsequent flattening or inversion of the T wave, copyright. principal value is to rule out tuberculous or malig- was first described by Porte & Pardee (1929). The nant foci, or other causes of pericarditis which variations of this pattern in acute non-specific could result from direct spread and to establish pericarditis have been comprehensively reviewed the presence and follow the course of significant by Soffer (1960). pericardial effusions. Bradley (1964) points out Blood. Anaemia, if present at all, is never more that 250 ml of fluid may be present in the peri- than mild. The erythrocyte sedimentation rate is cardium in the adult before the heart appears usually moderately elevated in the early stages, enlarged radiologically, and suggests a lateral film generally between 20 and 30 mm/hr, Westergren with the patient leaning forward to show fluid in (Martin, 1966). However, as in our patient who http://pmj.bmj.com/ the pericardium below and in front of the heart had been ill for 8 months, the ESR may be normal shadow. The most significant radiological finding throughout. A return to normal from a previously is a sudden change in heart size in the absence of high reading must not be used as an indication clinical evidence of heart failure. Rapid increase in for ambulation of the patient, especially if steroids heart size associated with clinical evidence of a are being used (Bradley, 1964). Leucocytosis with raised jugular venous pressure with a systolic absolute neutrophilia is present in about half the descent in its wave form and pulsus paradoxus patients on admission to hospital (Johnson et al., on October 2, 2021 by guest. Protected should suggest the development of cardiac tam- 1961). Most of the remainder have a normal total ponade. Conversely, progressive reduction in heart white cell count with or without some relative size without resolution of these clinical signs neutrophilia (Bradley, 1964). In two of our own should suggest that the patient may be developing patients and in one of Martin's (1966), neutro- pericardial constriction. Pleural effusions are pre- paenia was observed. Serum transaminases are sent in two-thirds of the patients with pericardial universally normal in uncomplicated acute non- effusions (Bradley, 1964). specific pericarditis (Bradley, 1964) and are a Fluoroscopy is of limited value but may show useful means of distinguishing between post- some diminution in the pulsation of the heart in myocardial infarction syndrome and an extension pericardial effusion or constriction. of the original myocardial infarction. Cardiac catheterization and angiography are Virus studies. A search for evidence of recent seldom justified except where pericardial constric- virus infection particularly with the Coxsackie B tion is suspected, when injection of contrast group should be made in every suspected case of medium into right atrium with cine-angiography acute non-specific pericarditis. The virus may be Postgrad Med J: first published as 10.1136/pgmj.43.502.534 on 1 August 1967.
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