Pericardial Disease
Todd L. Kiefer
Randall Vagelos
Etiologies: Idiopathic, viral, tuberculosis (TB), coccidiomycosis, uremia, collagen vascular diseases, neoplasm, trauma, post-myocardial infarction—two types: 1 to 3 days post-transmural infarct and weeks to months postinfarction (Dressler syndrome), prior external beam radiation, HIV
Clinical presentation: Substernal chest pain, pleuritic in nature, +/− radiation to left arm, often radiates to trapezius, pain diminished with sitting up and leaning forward, pain exacerbated with lying supine
Patient may provide history of fever or recent viral illness
Differential diagnosis: Myocardial infarction, pulmonary embolism, aortic dissection, pneumothorax, pleurisy, costochondritis, gastroesophageal reflux
Physical exam: Triphasic (ventricular systole, early diastole, and atrial contraction) friction rub in 85% of patients, radiates from left lower sternal border to apex, exam often fluctuates
Electrocardiogram (ECG): Diffuse ST segment elevation with the exception of leads avR and V1
FOUR STAGES OF ECG ABNORMALITIES1
Diffuse concave S-T elevation and P-R depression
Normalization S-T and P-R segments
Diffuse T wave inversions
Normalization of T waves
Laboratory evaluation: +/− Elevated white blood cell count with lymphocyte predominance, elevated ESR suggests TB or autoimmune etiology, may see minimal troponin elevation (greater elevation suggests
myocardial infarction or myocarditis), blood cultures if fever and elevated WBC, pericardial fluid culture if purulent pericarditis is suspected and pericardiocentesis is performed
Echocardiography: Usually normal, may see pericardial effusion
Treatment: Nonsteroidal anti-inflammatory drugs—ibuprofen 600 to 800 mg p.o. tid for 2 weeks
Prednisone taper over weeks to a month if no improvement with ibuprofen
Consider evaluation for underlying etiology if recurrent
Colchicine (COPE Trial):3 One hundred twenty patients with first episode pericarditis from connective tissue disease, postpericardiotomy, or idiopathic etiology were randomized to aspirin+colchicine versus aspirin alone, and the aspirin+colchicine treatment arm resulted in significantly decreased symptoms at 3 days and recurrent symptoms at 18 months.
Predictors of worse outcome:1 Temperature >38°C, symptoms of several weeks duration in an immunosuppressed patient, traumatic etiology, development of pericarditis while on oral anticoagulation, large effusion greater than 20 mm, evidence of purulent pericarditis without antibiotic treatment >24 hours, postradiation pericarditis often progresses to effusive/constrictive pericarditis
Complications: Enlarging effusion progressing to cardiac tamponade, development of chronic constrictive pericarditis
