see also:

• the adult patient with chest pain in the ED
• Paient UK information sheet on pericarditis

• acute “viral”/“idiopathic” pericarditis has generally a brief and benign course after empiric treatment by aspirin (acetylsalicylic acid) or non-steroidal anti-inflammatory drugs (NSAIDs), and routine hospitalization of most patients may be unnecessary.
• complications develop in ~20% ¹⁾:
  • recurrent pericarditis 18%
    • risk factors include:
      • lack of response to non-steroidal anti-inflammatory drugs (NSAIDs)
      • need for corticosteroid therapy
      • inappropriate pericardiotomy
      • creation of a pericardial window
  • cardiac tamponade <5%
  • constrictive pericarditis 1.5%
• NB post-infarct pericarditis is not included in this entity on this page

• “viral” or “idiopathic” (>80%)
• post-infarction regional pericarditis (PIRP)
  • occurs in the days following transmural STEMIs as the epicardium is involved with subsequent inflammation of the pericardium
  • this results in either:
    • persistent ST elevation with upright T waves > 48hrs post-STEMI
    • gradual reversion of inverted T waves to upright Twaves within 48-72hrs post-STEMI in association with well formed Q waves
  • these patients are at risk of:
    • myocardial rupture causing cardiac tamponade or, if it is a septal AMI, an acute VSD with L-to-R shunt and APO/cardiogenic shock
    • LV aneurysm and mural thrombus
  • see http://hqmeded-ecg.blogspot.com.au/2014/07/subacute-anteroseptal-stemi-with.html
• auto-immune (7%)
• neoplastic (5%)
• tuberculosis (TB) (4%)
• purulent (<1%)
• chylopericardium is a rare disorder that may be primary (ie, idiopathic) or, more often, secondary to injury to the thoracic duct such as in trauma or post-operative
  • chylothorax, with or without chylopericardium, is much more common than isolated chylopericardium. Most cases are nontraumatic, with the major cause being malignancy, particularly lymphoma.

• anterior chest pain
  • typically sharp, worse on inspiration and on lying down
  • may be dull
  • may radiate to shoulders
• may have a pericardial friction rub
  • highly specific but low sensitivity as they are quite variable from hour to hour, and may not be heard if there is an effusion
  • superficial scratchy or squeaking quality that is best heard with firm pressure of the diaphragm of the stethoscope, with patient leaning forwards or resting on elbows and knees so that contact between visceral and parietal pericardium is maximised
  • ask patient to stop breathing to differentiate from a pleural rub
• may have a pericardial effusion
  • 40% do NOT have a pericardial effusion
  • of the remainder, ~80% have a small effusion and 10% have a moderate effusion
  • 5% develop life threatening cardiac tamponade²⁾
• may have recent or current viral infection
• 15% also have evidence of viral myocarditis hence called myopericarditis but this is usually benign ³⁾
  • diagnosed by either:
    • raised troponin (does not appear to have any prognostic value)
    • impaired LV ejection fraction on echo
  • risk factors include:
    • arrhythmias (odds ratio (OR) = 17.6, 95% confidence interval (CI) 5.7 to 54.1; p<0.001)
    • male gender (OR = 6.4, 95% CI 2.3 to 18.4; p = 0.01)
    • age <40 years (OR = 6.1, 95% CI 2.2 to 16.9; p = 0.01)
    • ST elevation (OR = 5.4, 95% CI 1.4 to 20.5; p = 0.013)
    • recent febrile syndrome (OR = 2.8, 95% CI 1.1 to 7.7; p = 0.044)

• 1st described by Spodick et al
• less than half of all patients evolve through all stages
• ECG changes are due to inflammation of the epicardium
• tachycardia may be the only ECG finding if ST elevation has resolved & T waves remain normal
• stage 1:
  • lasts hrs-days
  • diffuse PR depression leads I,II,III,aVL, aVF, V2-6 with reciprocal elevation in aVR, V1
  • widespread ST elevation, 2-5mm concave & upward in leads I, II, III, aVF & V2-5 and reciprocal depression if present, only in aVR & V1
  • slight elevation of PR segment in aVR
• stage 2:
  • a few days later
  • ST & PR segments become isoelectric with flattened or upright T waves
• stage 3:
  • diffuse T wave inversion
• stage 4:
  • lasts days - weeks
  • T waves normalise, but rarely, remain normal

• ST elevation occurs in BOTH limb leads and precordial leads in pericarditis whereas 50% with early repolarization have no ST deviations in the limb leads
• PR and ST/T wave evolutionary changes do not occur in early repolarization
• ratio of ST elevation to T wave amplitude in lead V6 > 0.24 indicates pericarditis ⁴⁾

• usually related to the presence of either:
  • pericardial effusion
    • ⇒ low voltage amplitude in all leads
    • ⇒ electrical alternans may occur with large effusions or tamponade
  • constrictive pericarditis
    • ⇒ low voltage amplitude in all leads but no electrical alternans
    • ⇒ left atrial abnormalities
• NB. myxoedema also causes low voltages but usually bradycardia as well whereas pericarditis tends to cause tachycardia

• exclude other potential causes of chest pain if Dx is not clear
• CXR to help exclude a large effusion or evidence of LVF
• ECG
• FBE, U&E, troponin
• consider CRP
• viral studies are NOT indicated
• consider need to test for tuberculosis (TB), HIV / AIDS, and auto-immune disorders (eg. consider ANA)
• if low risk:
  • then discharge home
  • aspirin (acetylsalicylic acid), or non-steroidal anti-inflammatory drugs (NSAIDs) if no C/I
    • consider avoiding or using lower dose non-steroidal anti-inflammatory drugs (NSAIDs) if myocarditis is also present as animal models of myocarditis, NSAID are not effective and may actually enhance the myocarditic process and increase mortalitynt J Cardiol. 2008 Jun 23;127(1):17-26))
    • avoid non-steroidal anti-inflammatory drugs (NSAIDs) in post-AMI pericarditis
    • if C/I to NSAIDs such as pregnancy, or if patient needs steroids for other conditions, then can use short courses of corticosteroids instead of NSAIDs but steroids may increase rate of recurrence
  • colchicine 500mcg bd in addition to NSAIDs to reduce rate of recurrence
  • proton pump inhibitors (PPIs) if need longer term NSAIDs
  • consensus is that all patients should have an early echo
    • early OP echo if echo cannot be done that day
  • warn patient of features of tamponade which would mandate urgent reassessment, although tamponade is very rare in low risk patients ⁵⁾
• if high risk
  • admit
  • urgent echo
  • emergency therapeutic pericardiocentesis if cardiac tamponade is present
  • diagnostic pericardiocentesis should be considered if:
    • suspect a malignant or bacterial etiology, or,
    • in patients with an effusion refractory to medical therapy
  • patients who fail to respond to NSAIDs after 2 weeks may benefit from colchicine or corticosteroids

• fever >38 degrees C (HR 3.56, 95% CI 1.82 to 6.95; P<0.001)
• subacute onset (HR 3.97, 95% CI 1.66 to 9.50; P=0.002)
• immunosuppression
• trauma
• oral anticoagulant therapy
• myopericarditis
• large pericardial effusion (HR 2.15, 95% CI 1.09 to 4.23; P=0.026)
• cardiac tamponade
• raised troponin
• failure to respond to aspirin or NSAID Rx (9% develop constriction vs 0.5% of those who respond to aspirin, HR 2.50, 95% CI 1.28 to 4.91; P=0.008) )^{6) 7)}