Diagnosing Pericarditis KRISHAN K

Diagnosing Pericarditis KRISHAN K. GOYLE, M.D., and ANNE D. WALLING, M.D. University of Kansas School of Medicine, Wichita, Kansas Pericarditis, or inflammation of the pericardium, is most often caused by viral infection. It can also develop as a result of bacterial or other infection, autoimmune disease, renal failure, injury to the mediastinal area, and the effects of certain drugs (notably hydralazine and procainamide). The clinical features of pericarditis depend on its cause, as well as the volume and type of effusion. Patients with uncomplicated pericarditis have pleu- ritic-type chest pain that radiates to the left shoulder and may be relieved by leaning forward. Chest radiographs, Doppler studies, and laboratory tests confirm the diagno- sis and provide information about the degree of effusion. In most patients, pericarditis is mild and resolves spontaneously, although treatment with a nonsteroidal anti-inflammatory drug or a short course of a corticosteroid may be helpful. When a large pericardial effusion is produced, cardiac function may be compromised, and cardiac tamponade can occur. In patients with longstanding inflammation, the pericardium becomes fibrous or calcified, resulting in constriction of the heart. Drainage or surgical intervention may be necessary in patients with complicated pericarditis. (Am Fam Physi- cian 2002;66:1695-702. Copyright© 2002 American Academy of Family Physicians.) ericarditis is inflammation of the physicians should be alert to the possibility of pericardial sac surrounding the pericarditis in patients with chest pain, heart and the origins of the great because misdiagnosis can have potentially vessels.1 The condition is most fatal consequences. In particular, hemorrhage often caused by a viral infection and fatal cardiac compression can occur if Pand generally resolves in a few weeks with no thrombolytic therapy is given to patients who sequelae. have pericarditis. Severe pericardial syndromes are relatively uncommon, and their clinical features are Etiology largely determined by the amount and type of Although viral infection is the most com- fluid produced by the inflammatory process.1,2 mon cause of pericarditis,5 the condition has The normal pericardial sac contains 15 to many possible causes6,7 (Table 1),including 20 mL (maximum: 50 mL) of serous fluid, bacterial infection, myocardial infarction, which lubricates cardiac motion.3 In pericardi- trauma, malignancy, uremia, hypothyroidism, tis, the accumulation of serous fluid, inflam- collagen vascular disease, and the effects of matory cells, and fibrin may compromise car- certain drugs, notably hydralazine (Apreso- diac function. line) and procainamide (Pronestyl). Purulent Over time, pericarditis can result in chronic pericarditis as a result of bacterial infection inflammation with thickening and, ultimately, (e.g., tuberculosis) is now rare, but human calcification of the pericardium. This condi- immunodeficiency virus infection has tion is known as “chronic constrictive peri- become an increasingly common cause of the carditis.” Conversely, rapid accumulation of condition.8,9 Many infections that cause peri- serous fluid can result in acute compression of carditis, particularly fungal and nonbacterial the cardiac chambers, with dire hemodynamic infections, occur most often in immuno- consequences.3,4 This condition, which is compromised patients. called “cardiac tamponade,”may occur in up to Pericarditis may complicate myocardial 15 percent of patients with severe pericarditis.2 infarction on the second to fourth day after the Pericarditis can mimic other conditions, acute event as a reaction to underlying necrotic especially myocardial infarction. Family myocardium. The condition may also be a NOVEMBER 1, 2002 / VOLUME 66, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1695 TABLE 1 Etiology of Pericarditis prominent feature of postmyocardial infarc- Idiopathic (nonspecific, probably viral) tion syndrome (Dressler’s syndrome), which Infectious causes develops weeks to months after acute infarc- Viruses: coxsackievirus A and B, hepatitis viruses, human immunodeficiency virus, measles virus, mumps virus, varicella virus tion. In this situation, pericarditis occurs Bacteria: gram-positive and gram-negative organisms; rarely, Mycobacterium because of a late autoimmune reaction stimu- species (tuberculosis) lated by the entry of necrotic myocardial tissue Fungi (most often in immunocompromised patients): Blastomyces dermatitidis, into the circulation, where it acts as an antigen. Candida species, Histoplasma capsulatum Pericarditis is a feature of several autoim- Noninfectious causes mune conditions, especially systemic lupus Acute myocardial infarction* erythematosus. It is also associated with renal Renal failure† failure and hemodialysis. Furthermore, peri- Malignancy: breast cancer, lung cancer, Hodgkin’s disease, leukemia, lymphoma by local invasion carditis can develop because of injury to the Radiation therapy (usually for breast or lung cancer) pericardium as a result of trauma, surgery, Autoimmune disorders: mixed connective tissue disorder, hypothyroidism, instrumentation, or radiation therapy. inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, Wegener’s granulomatosis, Takayasu’s arteritis6 Pathophysiology and Classification Trauma (including surgery): closed procedures and pacemaker implantation Depending on the underlying cause, the (puncture of myocardium) acute inflammatory response in pericarditis Drugs‡: hydralazine (Apresoline), procainamide (Pronestyl), phenytoin (Dilantin), isoniazid (e.g., Nydrazid); with rifampin (Rifamate), may produce serous fluid, pus, or dense fibrin- phenylbutazone, dantrolene (Dantrium), doxorubicin (Adriamycin, Rubex), ous material. Viral pericarditis usually results methysergide (Sansert), penicillin, mesalamine (Rowasa)7 in small accumulations of serous fluid that resolve spontaneously or require minimal *—Pericardial effusion may occur on the second to fourth day after acute therapeutic intervention. Even large volumes myocardial infarction as a reaction to underlying necrotic myocardium in up to of serous fluid (up to 250 mL) may not cause 25 percent of patients. It can also develop weeks to months after myocardial significant clinical signs or symptoms if accu- infarction in patients with postmyocardial infarction syndrome (Dressler’s syndrome); in this situation, pericarditis occurs because of a late autoimmune reac- mulation is gradual. The effusion may only be tion stimulated by the entry of necrotic myocardial tissue into the circulation, apparent as an enlarged cardiac silhouette on where it acts as an antigen. the chest radiograph.3 †—Pericarditis in uremia indicates a need for dialysis; pericarditis may also be Conversely, large acute accumulations of associated with hemodialysis. pericardial fluid may cause intrapericardial ‡—Listed in relative order of frequency. pressure to rise, thereby impeding filling of the right side of the heart through the superior vena cava and inferior vena cava. Acutely, this situation can result in cardiac tamponade. If The Authors the pericarditis process continues and the fluid KRISHAN K. GOYLE, M.D., has a private cardiology practice and is also associate pro- organizes into a thickened (even calcified) fessor at the University of Kansas School of Medicine, Wichita. Dr. Goyle received his coating, the resultant constrictive pericarditis medical degree from All India Institute of Medical Sciences, New Delhi. He completed may mimic restrictive cardiomyopathy.4,10,11 an internal medicine residency at the University of Rochester (N.Y.) and a cardiology fellowship at the Cleveland Clinic Foundation. Thus, pericarditis may be classified as acute, subacute, or chronic, depending on the under- ANNE D. WALLING, M.D., is associate dean for faculty development and professor in the Department of Family and Community Medicine at the University of Kansas School of lying pathophysiologic process (Table 2). Medicine, Wichita. Dr. Walling received her medical degree from the University of St. Andrews, Scotland, and completed postdoctoral training in community medicine and Hemodynamic Considerations public health in London. She is a former secretary-treasurer of the Society of Teachers of Family Medicine and presently serves as associate editor of American Family Physician. Changes in the jugular veins and the rela- tionship of those changes to respiration can be Address correspondence to Krishan K. Goyle, M.D., University of Kansas School of Medicine, 1010 N. Kansas, Suite 3207, Wichita, KS 67214-3199 (e-mail: kgoyle@ extremely useful in differentiating pericarditis yahoo.com). Reprints are not available from the authors. from other causes of chest pain and related 1696 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 9 / NOVEMBER 1, 2002 Pericarditis in early right ventricular diastolic collapse and TABLE 2 late diastolic right atrial collapse, because pres- Classification of Pericarditis sures are lowest in diastole. The y descent is blunted because the right ventricle cannot Acute pericarditis (<6 weeks) expand, but the x descent remains normal. In Effusive cardiac tamponade, some blood (though less Fibrinous than normal) still flows toward the right side of Subacute pericarditis (>6 weeks to 6 months) the heart during inspiration. Because the car- Chronic pericarditis (>6 months) diac chambers are inhibited from dilating, the Effusive inflow causes the intraventricular septum to Adhesive

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