Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial ECG changes. The first and last stages of ECG changes are seen in the images below.

Signs and symptoms

Chest pain is the cardinal symptom of pericarditis, usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm. Common associated signs and symptoms include low-grade intermittent fever, dyspnea/tachypnea (a frequent complaint and may be severe, with myocarditis, pericarditis, and cardiac tamponade), cough, and dysphagia. In tuberculous pericarditis, fever, night sweats, and weight loss are commonly noted (80%).

Specific causes of pericarditis include the following:

• Idiopathic causes
• Infectious conditions, such as viral, bacterial, and tuberculous infections
• Inflammatory disorders, such as RA, SLE, scleroderma, and rheumatic fever
• Metabolic disorders, such as renal failure and hypothyroidism
• Cardiovascular disorders, such as acute MI, Dressler syndrome, and aortic dissection
• Miscellaneous causes, such as iatrogenic, neoplasms, drugs, irradiation, sarcoidosis, cardiovascular procedures, and trauma

Diagnosis

Initial evaluation includes a clinical history and physical examination, ECG, echocardiography, chest radiography, and lab studies.

ECG can be diagnostic in acute pericarditis and typically shows diffuse ST elevation. The ratio of the amplitude of ST segment to the amplitude of the T wave in leads I, V4, V5, and V6 on electrocardiogram can be used to differentiate acute pericarditis (AP) from early repolarization (ER) and early repolarization of left ventricular hypertrophy (ERLVH), according to a recent study. When ST elevation was present in lead I, the ST/T ratio had the best predictive value for discriminating between AP, ER and ERLVH. The study involved 25 patients with AP, 27 with ER, and 28 with ERLVH. ^[1]

Echocardiography is indicated if pericardial effusion is suspected on clinical or radiographic grounds, the illness lasts longer than 1 week, or myocarditis or purulent pericarditis is suspected.

A chest radiograph is helpful to exclude pulmonary conditions that may be responsible for or are associated with the cause of pericarditis (ie, cancer, infection, SLE, sarcoidosis, etc). It is not helpful for evaluating the presence of pericardial fluid, as patients with small effusions (less than a few hundred milliliters) may present with a normal cardiac silhouette; it is only helpful for diagnosing fluid in patients with effusions larger than 250 mL.

Laboratory tests may include CBC; serum electrolyte, blood urea nitrogen (BUN), and creatinine levels; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels; and cardiac biomarker measurements, lactate dehydrogenase (LDH), and serum glutamic-oxaloacetic transaminase (SGOT; AST) levels. Serum titers for suspected infectious etiologies and testing for tuberculosis exposure (ie, PPD or interferon-gamma release assays) may be helpful.

Management

Treatment for specific causes of pericarditis is directed according to the underlying cause. For patients with idiopathic or viral pericarditis, therapy is directed at symptom relief.

Pharmacologic treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy. These agents have a similar efficacy, with relief of chest pain in about 85-90% of patients within days of treatment. A full-dose NSAID should be used, and treatment should last 7-14 days.

Colchicine, alone or in combination with an NSAID, can be considered for patients with recurrent or continued symptoms beyond 14 days. ^[2, 3]

Corticosteroids should not be used for initial treatment of pericarditis unless it is indicated for the underlying disease, the patient’s condition has no response to NSAIDs or colchicine, or both agents are contraindicated.

Surgical treatment

Surgical procedures for pericarditis include pericardiectomy, pericardiocentesis, pericardial window placement, and pericardiotomy.

Pericardiectomy is the most effective surgical procedure for managing large effusions, because it has the lowest associated risk of recurrent effusions. This procedure is used for constrictive pericarditis, effusive pericarditis, or recurrent pericarditis, steroid dependence, and/or intolerance to other medical management.

Patients with effusions larger than 250 mL, effusions in which size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade are candidates for pericardiocentesis.

Pericardial window placement is used for effusive pericarditis therapy. In critically ill patients, a balloon catheter may be used to create a pericardial window, in which only 9 cm² or less of pericardium is resected.

Consider subxiphoid pericardiotomy for large effusions that do not resolve. This procedure may be performed under local anesthesia and has a lower risk of complications than pericardiectomy.