Pericarditis Authors: Doctor Sabiha Gati BSc (Hons), MBBS and Doctor Sanjay Sharma BSc (Hons), MBChB, MRCP (UK), MD1 Creation Date: March 2005 Scientific Editor: Professor William McKenna 1 University Hospital Lewisham, Lewisham High Street, London SE13 6LH. [email protected] Abstract Keywords Background Definition and Classification Frequency ACUTE PERICARDITIS Clinical manifestation Other investigations Management Complications PERICARDIAL EFFUSION CARDIAC TAMPONADE Clinical Manifestations Investigations Management CONSTRICTIVE PERICARDITIS Clinical manifestations Investigations Management References Abstract Pericarditis is an inflammatory disorder of the serous pericardium resulting from a primary insult to the heart or is secondary to a systemic disorder. Of the many causes, the most frequently encountered include acute idiopathic pericarditis and viral infections. The condition is classically diagnosed by the presence of chest pain, presence of a pericardial friction rub and characteristic changes on ECG. Extensive investigations to elicit a cause are not necessary as they are of low diagnostic yield. Because of its frequently self-limiting nature, non-steroidal anti-inflammatory drugs are normally used as the first line treatment with the aim of dampening the inflammatory process and expediting recovery. Specific therapy should be initiated for an underlying disorder perpetuating pericarditis. Complications of pericarditis include pericardial effusions and subsequent tamponade and long term constrictive pericarditis. Further laboratory evaluation, echocardiography and pericardiocentesis should be considered for individuals likely to have these complications. Keywords Pericarditis, pericardial effusion, pericardial constriction the two layers of the serous pericardium that normally Background contains 15 to 50 mls of plasma fluid (1). The heart is surrounded by a protective pericardium made up of two layers, a serous and a fibrous Definition and Classification component. The serous component is further divided Pericarditis is an inflammatory disorder of the serous into an inner, visceral and outer, parietal layer. A pericardium which may result from either a primary potential space, the pericardial cavity exists between insult directly to the heart or be secondary to a large number of systemic disorders (Table 1). In most Gati S., Sharma S. Pericarditis. Orphanet Encyclopedia, March 2005. 1 http://www.orpha.net/data/patho/GB/uk-Pericarditis.pdf instances the disorder is self-limiting but may be ACUTE PERICARDITIS complicated by pericardial effusion or constriction. Aetiology Table 1: Diseases affecting the pericardium. The cause of pericardial disease in many cases is Adapted from (1). unknown, particularly in young adults. Studies suggest Trauma Myocardial Infarction a viral aetiology (coxsackie B) in most cases. Since Radiotherapy the disease is usually self-limiting the cause is not Aortic dissection investigated as there is a considerable time lag before Blunt or penetrating injury the results of the viral titre are available and the Infection Bacterial – Tuberculosis, initiation of treatment. The diagnosis can be made Streptococcus, Staphylococcus, from the clinical presentation and does not require Pneumococcus, Haemophilus, positive virology titres. Individuals may present with Legionella, Salmonella, Lyme disease, chest pain and flu-like symptoms. Although the Neisseria meningitides & Gonorrhoea, condition is self-limiting, recurrence over the following Chlamydia psittaci & Trachomotis 6 to 12 months may occur with an immunological Viral – HIV, Coxsackie virus A&B, basis. echovirus, EBV, mumps, hepatitis B, influenza, varicella Viral pericarditis Fungal – Histoplasmosis, aspergillosis, Coxsackie virus A & B, echovirus, adenovirus and HIV nocardia, candida, coccidiomycosis are the most commonly implicated viral causes of Parasitic – Echinococcus, amebiasis, acute pericarditis. Seasonal epidemics are known to toxoplasmosis occur with influenza and coxsackie B. Viral pericarditis Neoplasm Primary or secondary is typically self-limiting, lasting 1-3 weeks and is Drugs Hydralazine, Procainamide, Cytotoxics, treated symptomatically. HIV can facilitate infection of Phenytoin, Penicillin, Anticoagulants the pericardium by non-virulent organisms or can Endocrine Hypothyroidism directly infect the pericardium. HIV typically causes small asymptomatic pericardial effusions. Metabolic Uraemia, Amyloidosis Inflammatory Dressler’s syndrome, Postcardiotomy Bacterial pericarditis Connective RA, SLE, SS, PAN, Churg-strass, The most common bacterial causes are Tissue GCA, sarcoidosis, IBD, wegener’s Staphylococcus aureus, Streptococcus pneumonie, disorders granulomatosis Haemophilus influenzae and Mycobacterium Acute tuberculosis. The spread is either haematogenous or Idiopathic directly from the lungs or pleura. Less common HIV= Human immunodeficiency virus, EBV= Ebstein bacterial infections may be seen in the bar virus, RA= Rheumatoid arthritis, SLE= Systemic immunocompromised and in those with altered lupus erythematosus, SS= Systemic sclerosis, PAN= bacterial flora from extensive prolonged antibiotic Polyarteritis nodosa, GCA= giant cell arteritis, IBD= therapy. inflammatory bowel disease. Tuberculosis pericarditis Frequency Tuberculous pericarditis is rare in the western world, Epidemiological data on the incidence of pericarditis however, it is still an important cause of pericardial are scarce, possibly because the condition can be disease in the third world. Both parietal and visceral difficult to identify, and of its self-limiting nature. The layers of pericardium are infected and the frequency of pericarditis can vary in numerous myocardium is involved in most cases. Tuberculous disorders (Table 2). Mortality may vary according to pericarditis can present in the form of acute the aetiology, being low with viral/idiopathic pericarditis, pericardial effusion or with constrictive pericarditis and very high with purulent pericarditis (2). pericarditis. Treatment is with antituberculous drugs. Steroids hasten recovery in the first 11 weeks but Table 2: Frequency of the disorder under should be avoided in tuberculous pericarditis different causes of pericarditis. Adapted from secondary to HIV syndrome. (14) Fungal infection Cause Accountable cases Fungal pericarditis is rare and is usually manifest in Infection immunocompromised patients. Histoplasma is the Bacterial 1-8% most common fungal organism in the immuno- Tuberculosis 4% sufficient individuals and is known to cause Viral 1-10% constriction and calcification. Infections with Autoimmune actinomycosis (Actinomyces), coccidiodomycosis Rheumatoid arthritis 11-50% (Coccidioides), Candida and Aspergillus have also Systemic lupus 25% (after autopsy 62%) been reported. erythematosus Systemic sclerosis 5-10%(after autopsy 70%) Malignancy Chronic Renal failure 12% Neoplastic disorders affecting the pericardium include Hypothyroidism 4% rare primary tumours such as mesotheliomas or Myocardial infarction 7-23% myosarcomas or, more commonly are secondary to Dressler’s syndrome 4% metastases from the lung, breast, gastro-intestinal Postcardiotomy 10-40% tract and haematological malignancies. Malignancy is frequently associated with moderate to large effusions Neoplasm 5-17% (2,3), and may lead to tamponade. Patients with Gati S., Sharma S. Pericarditis. Orphanet Encyclopedia, March 2005. 2 http://www.orpha.net/data/patho/GB/uk-Pericarditis.pdf neoplastic pericardial effusions may also present with pericardium may also be involved in allergic supraventricular arrhythmias, or features of hypersensitivity reactions to penicillins. constrictive pericarditis. Generally, malignant pericardial effusions require drainage. The diagnosis Clinical manifestation of neoplastic pericardial effusion is based on Clinical presentation of acute pericarditis consists of a cytological examination of pericardial fluid or direct triad of chest pain, pericardial friction rub and histological tests on the pericardium (4,5). Recurrent generalised widespread ST segment and T wave effusions are treated by surgical fashioning of a changes on the ECG. continuum window into the pleural cavity. Chest pain Hypothyroidism The onset of the pain is sudden. The pain is Hypothyroidism causes silent pericardial effusion that classically located in the retrosternal area and is rarely of haemodynamic significance. Low voltage characteristically sharp in nature with exacerbation complexes are seen on the ECG. Thyroxine during movement or deep inspiration. The intensity of replacement alone is sufficient to resolve the the pain decreases with sitting forward. Dyspnoea is pericardial effusion. the consequence of the pain aggravated by breathing. Myocardial infarction Pericardial friction rub Acute pericarditis and/or effusion, are manifested in Precordial examination of a patient with acute approximately 15% of patients following an myocardial pericarditis often reveals a scratchy superficial sound infarct (MI) (5,6,7,8). The overall incidence of MI audible over the precordium, in any position termed a induced pericardial disease is reduced by 50% with “pericardial rub”. The rub can be fleeting and may vary thrombolytic therapy (7). Infarct size and early with posture and is best heard with the diaphragm of initiation of thrombolytic therapy determines the the stethoscope at the left sternal border. A pericardial incidence and extent of pericardial involvement (7). rub can be distinguished from a pleural rub by