Acute Pericarditis: Diagnosis and Management MATTHEW J. SNYDER, DO, Nellis Family Medicine Residency Program, Nellis Air Force Base, Nevada JENNIFER BEPKO, MD, David Grant Medical Center Family Medicine Residency Program, Travis Air Force Base, California MERIMA WHITE, DO, Nellis Family Medicine Residency Program, Nellis Air Force Base, Nevada Acute pericarditis, inflammation of the pericardium, is found in approximately 5% of patients admitted to the emer- gency department for chest pain unrelated to acute myocardial infarction. It occurs most often in men 20 to 50 years of age. Acute pericarditis has a number of potential etiologies including infection, acute myocardial infarction, medication use, trauma to the thoracic cavity, and systemic diseases, such as rheumatoid arthritis. However, most etiologic evalu- ations are inconclusive. Patients with acute pericarditis commonly present with acute, sharp, retrosternal chest pain that is relieved by sitting or leaning forward. A pericardial friction rub is found in up to 85% of patients. Classic electro- cardiographic changes include widespread concave upward ST-segment elevation without reciprocal T-wave inversions or Q waves. First-line treatment includes nonsteroidal anti-inflammatory drugs and colchicine. Glucocorticoids are traditionally reserved for severe or refractory cases, or in cases when the cause of pericarditis is likely connective tissue disease, autoreactivity, or uremia. Cardiology consultation is recommended for patients with severe disease, those with pericarditis refractory to empiric treatment, and those with unclear etiologies. (Am Fam Physician. 2014;89(7):553- 560. Copyright © 2014 American Academy of Family Physicians.) CME This clinical content cute pericarditis is the most common causes must be considered.9 Localized to the conforms to AAFP criteria affliction of the pericardium. It is heart, acute pericarditis can occur second- for continuing medical education (CME). See diagnosed in approximately 0.1% ary to an MI or a dissecting aortic aneurysm. CME Quiz Questions on of patients hospitalized for chest Systemic conditions, such as malignancy, page 515. A pain and in 5% of patients admitted to the inflammatory responses, autoimmune dis- Author disclosure: No rel- emergency department for chest pain unre- orders (e.g., rheumatoid arthritis), and evant financial affiliations. lated to acute myocardial infarction (MI).1 uremia, can precipitate acute pericarditis. ▲ Patient information: Although acute pericarditis occurs in all External causes other than viral infections A handout on this topic, age groups and in men and women, it pres- include pharmacologic agents (e.g., hydrala- written by the authors ents most often in men 20 to 50 years of age.2 zine, isoniazid), radiation treatment, blunt of this article, is avail- Acute pericarditis by itself confers low mor- or sharp trauma to the thoracic cavity, and able at http://www.aafp. 9 org/afp/2014/0401/ tality; however, the high rate of recurrence bacterial infection. Most etiologic evalua- p553-s1.html. Access to and the difficulty of controlling symptoms tions are inconclusive. the handout is free and contribute to high morbidity. After an initial unrestricted. episode of acute pericarditis, 30% of patients Clinical Presentation and Diagnosis have a recurrence.3 Factors associated with HISTORY AND PHYSICAL EXAMINATION increased morbidity are shown in Table 1.4-6 In more than 95% of cases, patients with acute pericarditis present with acute Etiology retrosternal, sharp, pleuritic chest pain that Healthy pericardium consists of the inner varies in severity.10 The pain may radiate serous visceral layer and the outer fibrous into the neck, jaw, or arms, similar to an parietal layer that envelop the heart. About 15 MI. In contrast to the pain from myocardial to 50 mL of fluid, an ultrafiltrate of plasma, ischemia, chest pain from acute pericardi- separates these layers. Acute pericarditis can tis is exacerbated in the supine position, by result from a systemic disease or a process coughing, and with inspiration. The pain isolated to the pericardium (Table 2).2,7,8 In usually improves in the seated position or most immunocompetent patients, viral or by leaning forward, which reduces pres- idiopathic etiologies are common, but other sure on the parietal pericardium, but it is AprilDownloaded 1, 2014 from ◆ Volume the American 89, Number Family Physician 7 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 553- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Acute Pericarditis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Evaluation of patients with acute pericarditis should include a history, C 2, 7, 15 physical examination, electrocardiography, chest radiography, and baseline laboratory studies (i.e., complete blood count, basic metabolic panel, troponin-I and creatine kinase levels, erythrocyte sedimentation rate, and serum C-reactive protein levels). Additional laboratory testing and imaging are dictated by clinical presentation and risk factors. Transthoracic echocardiography should be performed in all patients with C 19 suspected acute pericarditis to exclude pericardial effusion and cardiac tamponade. Patients with acute pericarditis should be treated empirically with nonsteroidal C 7 anti-inflammatory drugs. Colchicine may be used as monotherapy or in combination with a nonsteroidal C 23 anti-inflammatory drug for the first episode of acute pericarditis. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. not relieved with nitrates.2 Acute chest pain Additional clinical findings reflective of may or may not occur in patients with ure- the underlying etiology, such as those con- mic pericarditis or pericarditis associated sistent with specific autoimmune disorders with rheumatologic disorders, although or malignancies, may occur in patients with pleuritic chest pain may be the initial pre- acute pericarditis. Patients with a bacterial sentation of systemic lupus erythematosus. etiology may present with fever, chills, and Dull, oppressive chest pain radiating to the leukocytosis, whereas those with a viral eti- trapezius ridges or shoulders may occur ology may present with influenza-like or with acute pericarditis, making it difficult gastrointestinal symptoms. to differentiate from other common or life- A pericardial friction rub, which is highly threatening causes of chest pain, such as MI specific and pathognomonic for acute pericar- or aortic dissection (Tables 311 and 49). ditis, occurs in up to 85% of patients, but its absence does not exclude the diagnosis.12 Fric- tion rubs are characterized by a superficial scratchy or squeaking quality with varying Table 1. Predictors of Severe Illness in Patients with Acute Pericarditis intensity that may come and go over a period of hours, and may be heard best with the Major absence of a pericardial effusion. The intensity Fever > 100.4°F (38°C) of the friction rub may be increased during Subacute onset auscultation by having the patient lean for- Evidence suggestive of cardiac tamponade ward or rest the elbows on the knees, applying Large pericardial effusion (an echo-free space firm pressure on the stethoscope diaphragm greater than 20 mm) during suspended respiration.9 Respiration Nonsteroidal anti-inflammatory drug therapy does not affect a pericardial friction rub and ineffective after seven days thus allows differentiation from a pleural rub. Minor Immunosuppressed state ELECTROCARDIOGRAPHIC FINDINGS History of oral anticoagulant therapy Electrocardiographic changes caused by sig- Acute trauma nificant pericardial inflammation occur in Elevated cardiac troponin level (suggestive of approximately 90% of patients with acute myopericarditis) pericarditis,2 with the possible exception of NOTE: Major predictors have been validated in multi- those with uremic pericarditis, and typi- variate analysis. cally evolve in four stages (Figure 12,9). Classic Information from references 4 through 6. changes include widespread concave upward ST-segment elevation and PR-segment 554 American Family Physician www.aafp.org/afp Volume 89, Number 7 ◆ April 1, 2014 Acute Pericarditis Table 2. Etiologies of Acute Pericarditis Infectious Noninfectious Hypersensitivity- or autoimmunity- Viral* Acute idiopathic* related Adenovirus Acute myocardial infarction* Medication induced (select drugs)* Coxsackie virus A and B Neoplastic* Anticoagulants Echovirus Primary tumors Hydralazine Epstein-Barr virus Fibroma Isoniazid Hepatitis Lipoma Minoxidil Human immunodeficiency virus Mesothelioma Phenytoin (Dilantin) Influenza Sarcoma Procainamide Mumps Metastatic tumors Metabolic disorders* Bacterial* Breast Gout Haemophilus Leukemia Myxedema Legionella Lung Renal insufficiency (i.e., dialysis pericarditis) Meningococcus Lymphoma Uremia Neisseria Melanoma Postcardiac injury Pneumococcus Sarcoma Postmyocardial infarction (Dressler Salmonella Trauma syndrome) Staphylococcus Direct pericardial injury Postpericardiotomy syndrome Streptococcus Cardiac injury (e.g., cardiac surgery, Posttraumatic