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Home , Acute pericarditis, Cardiovascular disease, Korotkoff sounds, Pericardial effusion, Pericardial friction rub, Pericarditis

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Atifur Rahman Clinical features and management David Liu

Relevant stressors and any upper gastrointestinal Background symptoms should be sought. Pericarditis is an important diagnosis to consider in a patient presenting with chest Examination includes cardiovascular pain. It is diagnosed in 5% of patients presenting to hospital emergency departments examination looking for acute changes including with in the absence of a . vital signs, and particularly looking for signs of Objective (clammy, , decreased This article describes the common features and management of pericarditis in the pressure), , elevated jugular general practice setting. venous pressure (JVP), changes in or lung Discussion sounds and peripheral oedema. Respiratory Characteristic clinical findings in pericarditis include pleuritic chest pain and localised musculoskeletal and abdominal and a on of the left lower sternal border. examinations are also likely to be indicated. may reveal diffuse PR depressions and diffuse ST segment Common causes of chest pain are shown in elevations with upward concavity. The most common aetiologies of pericarditis are Table 1.1 idiopathic and viral, and the most common treatment for these is nonsteroidal anti- inflammatory drugs and . The complications of pericarditis include effusion, Case study (continued) tamponade and . may present as a globular heart Michael stated that his pain was sharp and shadow on chest X-ray. The presence of effusion, constriction or tamponade can be worse on inspiration. It had a sudden onset, confirmed on . Tamponade is potentially life threatening and is did not radiate and was not associated with diagnosed by the clinical findings of decreased , elevated jugular venous any . It was relieved slightly pressure, muffled on auscultation and pulsus paradoxus. when he sat up and leaned forward. Michael had no cardiac risk factors and no past Keywords: pericarditis; chest pain/diagnosis medical conditions except for a recent ‘flu-like’ illness in the previous month. He had no risk factors for acquisition of HIV or , Case study and no history of kidney . On clinical examination, he was afebrile and, Michael, 32 years of age, presents to the except for a soft pericardial friction rub, he hospital emergency department with chest had no other positive findings. pain of 4 hours duration. Discussion Discussion History and examination History and examination findings These symptoms are characteristic of pericarditis, a Chest pain is a common presenting symptom. The common condition that is diagnosed in 5% of patients initial assessment is clinical. Important elements presenting to hospital with chest pain in the absence on history are a description of the pain and its of myocardial infarction.2 Pericarditis is typically associated symptoms and presence of risk factors associated with sharp retrosternal pain (present such as history of , renal in 98.3% of cases) that may radiate to the neck, impairment, , , dyslipidaemia, shoulder or arms.3 The pain is often worse when the positive family history of cardiac disease, and patient is supine and improves when upright smoking history. Cardiac and respiratory system or leaning forward. It may be aggravated by deep history and focused musculoskeletal history looking breathing, swallowing or coughing. specifically for trauma to area of pain are indicated. Pericardial friction rub is the most important

Reprinted from Australian Family Physician Vol. 40, No. 10, October 2011 791 clinical Pericarditis – clinical features and management

Table 1. Common conditions that cause chest pain1 Case study (continued) Michael’s ECG and chest X-ray are Life threatening causes of chest pain unremarkable. He had mild and Myocardial infarction moderately elevated C-reactive (CRP). Aortic Acute pulmonary Discussion Pericarditis with pericardial effusion/tamponade Electrocardiogram Findings in pericarditis can include diffuse PR Common aetiologies of chest pain presenting to general practice depression and diffuse ST elevation with upward Musculoskeletal/chest wall disease or (48.7% of cases) concavity (AMI typically produces ST elevation with Cardiovascular causes (16%) upward convexity). The ST elevation usually involves Psychogenic/psychosomatic causes (11.5%) more than one coronary vascular territory and there Pulmonary causes (10.3%) is usually an absence of reciprocal ST changes Gastrointestinal causes (8.2%) between III and aVL (Table 2, Figure 1).4 physical sign of pericarditis (present in 35% of cavity. occurs when this fluid Chest X-ray cases).3 It is a high pitched, scratching sound and accumulates under pressure and obstructs diastolic is heard most frequently at the left lower sternal filling of the heart. Myopericarditis is another Chest radiography is used to rule out pericardial border during expiration with the patient upright possibly serious , with extension of effusion and abnormalities in the and leaning forward. Other important clinical the to the myocardium which can or lung fields that may be responsible for a signs to look for are ≥38°C and signs of be associated with kinase and pericardial effusion (eg. lung carcinoma). It may tamponade (raised JVP, muffled heart sounds, elevations and regional wall motion abnormalities also help to exclude other causes of chest pain (eg. decreased blood pressure). Patients with findings on the echocardiogram. pneumothorax). supportive of tamponade should be transferred to hospital urgently. Table 2. Stages of development of ECG changes in pericarditis Other life threatening causes of chest pain Stage ECG change symptoms similar to that of I (a) Diffuse ST segment elevation (a) include pulmonary embolus (PE) and acute (double arrows) and PR segment myocardial infarction (AMI). Electrocardiogram depression (single arrow) (ECG) showing characteristic features may suggest a diagnosis. If the diagnosis is unclear, the patient (b) Reciprocal PR segment elevation (single arrows) and should be sent to hospital for urgent assessment. (b) ST segment depression (double Pericarditis preceded by viral respiratory or arrows) in aVR and occasionally V1 gastrointestinal symptoms is suggestive of a viral aetiology. These are self limiting and respond well to analgesia and anti-inflammatory treatment. Features suggestive of nonviral pericarditis include fever ≥38°C (bacterial pericarditis), II Normalisation of the ST segment (uraemic pericarditis), unsafe and PR segments sexual practices and intravenous drug use (HIV pericarditis), history of malignancy, and risk factors for previous tuberculosis acquisition. Suspicion of a nonviral nonidiopathic III Widespread inversions aetiology of the pericarditis should prompt referral (single arrow) for review by a cardiologist. Complications Complications of acute pericarditis include IV Normalisation of the T waves pericardial effusion (present in 60% of cases2), tamponade (5% of cases2), myopericarditis and recurrent pericarditis. Pericardial effusion is the abnormal accumulation of fluid in the pericardial

792 Reprinted from Australian Family Physician Vol. 40, No. 10, October 2011 Pericarditis – clinical features and management clinical

of recurrences. It is well tolerated with fewer side effects than NSAIDs.6 The role of systemic in pericarditis is controversial. High dose corticosteroids (ie. 1 mg/kg/ day) with a 2–4 week taper is considered in pericarditis secondary to connective tissue 6 Figure 1. Diffuse ST elevations and PR depression in all leads except aVR and V1, which show disease, uraemia or autoreactivity. reciprocal ST depression and PR elevation Case study (continued) Two weeks later, Michael presented to the A large cardiac silhouette with predominant Case study (continued) hospital with chest discomfort and increase in transverse diameter (globular or ‘water On the basis of his clinical findings, recent on exertion. Clinical examination revealed bottle’ shape) may indicate pericardial effusion. viral infection and low risk for ischaemic muffled heart sounds, decreased blood This is measured by dividing the maximal transverse heart disease, Michael was diagnosed with pressure and a pericardial rub on cardiac width of the cardiac silhouette by the maximal viral pericarditis. His symptoms improved auscultation. was internal thoracic diameter. A cardiothoracic ratio of with 400 mg oral four times daily. elevated and pulsus paradoxes of 25 mmHg 0.5 is the upper limit of normal. Unlike the enlarged was present. Management cardiac silhouette seen in , in pericardial effusion the lung field usually appears clear (Figure Nonsteroidal anti-inflammatory drugs (NSAIDs) Discussion 2). Comparisons with previous chest X-rays are are the mainstay of treatment. Ibuprofen is Michael’s clinical findings are consistent with useful. It is important to remember that a chest preferred for its favourable effect on the coronary tamponade from a pericardial effusion. Clinical X-ray may appear normal in the presence of a small flow and large dose range. Depending on severity manifestations of pericardial effusion are pericardial effusion (<250 mL). and response, 300–800 mg every 6–8 hours dependent on the rate of accumulation of fluid may be initially required and can be continued in the pericardial sac. Rapid accumulation of Other investigations for days or weeks, ideally until the effusion has small amounts of may cause A full blood count may reveal leukocytosis. disappeared.6 Gastrointestinal protection may be symptomatic elevation of intrapericardial pressures, C-reactive protein is usually elevated, although considered. while large but slowly progressing effusions can it is not specific. A troponin rise is detectable in Colchicine (0.5 mg twice daily) added to an be asymptomatic. The classic triad of pericardial more than 30% of cases as inflammation of the NSAID or as monotherapy also appears to be tamponade includes: epicardium can to troponin release. However, effective for the initial attack and the prevention • dilated neck unlike , elevated troponin in pericarditis is not a negative prognostic marker.5 Table 3. Clinical signs in the diagnosis of pericardial effusion Cardiovascular • Pulsus paradoxus: an exaggeration of physiologic respiratory variation in systemic BP, defined as a decrease in systolic BP >10 mmHg with inspiration, due to reduced during inspiration • Kussmaul sign is a rise in JVP on inspiration. Kussmaul sign is seen in conditions in which right ventricular filling is limited by pericardial fluid, and in noncompliant or myocardium • Tachycardia • Hepatojugular reflux: this can be observed by applying pressure to the periumbilical region. A rise in the JVP of >3 cm H2O for more than 30 seconds suggests elevated central venous pressure (transient elevation in JVP can be normal) • Pericardial rub Respiratory • Tachypnoea • Decreased breath sounds

Figure 2. A large heart silhouette on chest Abdominal • Hepatosplenomegaly X-ray due to pericardial effusion. Other Other • Weakened peripheral common causes of a large heart silhouette • Oedema include dilated •

Reprinted from Australian Family Physician Vol. 40, No. 10, October 2011 793 Pericarditis – clinical features and management clinical

drained. Michael’s symptoms were relieved, and he recovered over the next day. He was discharged on oral colchicine and ibuprofen with a follow up echocardiogram in 10 days. Management is indicated for effusions that are moderate to large and are symptomatic, where medical management has been unsuccessful, or where pericardial fluid is needed for diagnostic purposes. Prompt referral to hospital for pericardiocentesis in hemodynamically significant Figure 3. ECG showing poor R-wave progression and , best demonstrated in V1–V4 pericardial tamponade may be lifesaving. Colchichine at 0.6 mg twice daily for 3–6 months • a fall in blood pressure, and Discussion as an adjunct to conventional treatment has been • muffled heart sounds. Electrical alternans is an alternation in the shown to be effective for preventing recurrent Other clinical findings of pericardial effusion are amplitude of QRS complexes. It is thought to be pericarditis. There is little evidence of its efficacy shown in Table 3. Fever ≥38°C, large pericardial due to the swinging movement of the heart within as monotherapy and it is ineffective when used in effusion or cardiac tamponade, or failure to improve the pericardial cavity (Figure 3). The combination patients with chronic pericardial effusions with a with or NSAIDs are risk factors associated of low voltage QRS complexes (≤5 mm) in limb normal CRP.7 with complications.3 leads and tachycardia should always raise concern Case study (continued) about tamponade. Other causes of this combination Mechanism and measurement of Michael’s 10 day follow up transthoracic include chronic obstructive pulmonary disease and pulsus paradoxus echocardiogram showed an asymptomatic pleural effusion. re-accumulation of 1.7 cm of fluid and 250 During inspiration, the negative intrathoracic Referral for echocardiography is useful for mL of blood stained fluid was drained and pressure increases, resulting in increased venous confirming the presence and size of an effusion. collected for investigation. When recovered, return to the heart. The right ventricle distends, In circumstances where clinical evaluation is Michael was discharged with an appointment causing the to bulge into not reliable, echocardiography can be useful in for specialist outpatient follow up in 2 weeks. At this appointment further tests were the left ventricle. This results in a decrease in detecting cardiac tamponade. ordered including tumour markers (alpha the left ventricular end diastolic volume, thus Case study (continued) fetoprotein, carcinoembryonic antigen decreasing volume and arterial pressure Pericardiocentesis was performed and 900 [CEA], carcinoma antigen [CA] 15.3), blood during . As intrapericardial pressures rise mL of blood stained fluid was successfully and pericardial fluid cultures for tuberculosis this effect becomes pronounced. The converse is true for expiration. To measure pulsus paradoxus the cuff is inflated above systolic pressure. are sought over the brachial while the cuff is deflated slowly. Initial Korotkoff sounds are heard only during expiration. The cuff is then deflated to the pressure at which Korotkoff sounds become audible during both inspiration and expiration. When the differences between these two levels exceeds 10 mmHg during quiet respiration, pulsus paradoxus is present. Case study (continued) An ECG and chest X-ray were performed. Initial blood tests were similar to those of his first presentation. Michael was admitted and a Figure 4. Michael’s initial echocardiogram showing pericardial effusion of up to 23 transthoracic echocardiogram was performed mm fluid posteriorly with early tamponade which showed up to 23 mm pericardial RV = right ventricle; RA = right atrium; LV = left ventricle; LA = left atrium; effusion with early tamponade (Figure 4). PF = pericardial fluid

Reprinted from Australian Family Physician Vol. 40, No. 10, October 2011 795 clinical Pericarditis – clinical features and management and pericardial fluid cytology. These were Table 4. Causes of pericarditis/pericardial effusion negative and computerised tomography (CT) scan of the /chest did not Cause Prevalence Test show malignancy or lymphadenopathy and Idiopathic Most common Often relates to lack of extensive HIV serology was negative. Michael was diagnostic evaluation. Many also investigated for autoimmune disease. patients with idiopathic However, other than a mild unspecific pericarditis have had a recent viral infection elevation in antinuclear antibodies (ANA), autoimmune markers (ENA, pANCA, cANCA, Infectious Most common cause of Serologic test for HIV in high risk infectious pericarditis. patients dsDNA) were negative. Viral/HIV Common organisms include Serology for other viral organisms Discussion coxsackie A and B and not routinely performed, echovirus. Pericarditis may as it is low yield and the Recurrence of hemorrhagic effusion is concerning, be preceded by a prodrome of result is unlikely to influence and when it occurs it is important to exclude upper respiratory symptoms management serious causes of pericardial effusion such as Bacterial May occur following High mortality. Prompt blood and malignancy, tuberculosis and HIV. Michael’s pneumonia pericardial fluid culture may help find the offending organism diagnosis on discharge was recurrent viral Suggested by fever ≥38°C pericarditis. As malignancy is a common cause Tuberculosis The aetiologic spectrum of Chest radiography, tuberculin pericarditis is different in test, histology, cultures of recurrent hemorrhagic pericarditis, pericardial developing countries, which tissue biopsy was considered to rule this out as have a higher prevalence of he had re-presented with pericardial effusion.8 tuberculosis Other causes of pericardial effusion are described Autoimmune Rheumatoid , Rheumatoid factor, complement in Table 4. systemic erythematosus levels, antinuclear antibodies Key points Neoplastic Malignancies with the Chest radiography, pericardial highest prevalence of fluid cytology, tumour markers • Pericarditis is a common disease with pericardial effusion include Hemorrhagic effusion characteristic clinical findings. lung (37%), breast (22%), and • Clinical diagnosis is made by the presence leukaemia/lymphoma (17%) of characteristic chest pain symptoms, the Postoperative Common after History, evidence of polyserositis, high ESR presence of a pericardial friction rub and Following MI Often associated with a large History characteristic ECG findings. anterior myocardial infarction Echocardiography • In Australia, it is most commonly of viral or Aortic Rare Trans-oesophageal idiopathic origin, both of which generally have a dissection echocardiography, CT aortogram, brief and benign course. magnetic resonance imaging • NSAIDs and colchicine remain the mainstay of Uraemia Patients with chronic kidney Urea and creatinine treatment for pericarditis. disease, before or after • Cardiac tamponade is a serious complication Guidelines on the diagnosis and management of pericarditis and can be diagnosed clinically References 1. Verdona F, Herziga L, Burnandb B, Bischoffa T, of pericardial executive summary: the by the presence of decreased blood pressure, Pecoudc A, Junoda M. Chest pain in daily practice: Task Force on the Diagnosis and Management of elevated JVP, muffled heart sounds on occurrence, causes and management. The TOPIC Pericardial Diseases of the European Society of . Eur Heart J 2004;25:587–610. auscultation, and pulsus paradoxus. study. Swiss Med Weekly 2008;138:240–7. 2. Imazio N, Demichelis B, Parrini I, et al. Day-hospital 7. Imazio M, Spodick DH, Brucato A, Trinchero treatment of acute pericarditis: a management R, Adler Y. Controversial issues in the man- Authors program for outpatient therapy. J Am Coll Cardiol agement of pericardial diseases. Circulation Atifur Rahman FRACP, is Director of Clinical 2004;43:1042–6. 2010;121:916–28. Services, Coronary Care Unit, Gold Coast Hospital 3. Lange RA, Hillis LD. Acute pericarditis. N Engl J 8. Shabaz Sarwar CM, Fatimi S. Characteristics of recurrent pericardial effusions. Singapore Med J and Associate Professor, Griffith University School Med 2004;351:2195–202. 2007;48:725–8. of , Gold Coast, Queensland. atifur@ 4. Spodick DH. Diagnostic electrocardiographic hotmail.com sequences in acute pericarditis: significance of PR segment and PR vector changes. Circulation David Liu MBBS(Hons), BSc, is resident, Gold Coast 1973;48:575–80. Hospital and Associate Lecturer, Griffith University 5. Imazio M, Cecchi E, Demichelis B, et al. School of Medicine, Gold Coast, Queensland. Indicators of poor prognosis of acute pericardi- tis. Circulation 2007;115:2739–44. Conflict of interest: none declared. 6. Maisch B, Seferovic PM, Ristic AD, et al.

796 Reprinted from Australian Family Physician Vol. 40, No. 10, October 2011