11/14/24, 10\:50 AM Pericarditis

Pericarditis

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Key points ⚡
Succinct notes to superpower your revision
Pericarditis\: in
admissions and 5% of ED admissions for chest pain.
Causes\: idiopathic in most cases. Other causes include\:
Infections\: viruses (e.g. coxsackievirus, HIV), bacteria (e.g. staphylococcus, M y c o b a c t e r i u m t u b e r c u l o s i s ), fungi (e.g.
histoplasmosis)
Acute MI (1-3 days post-infarction)
Dressler’s syndrome (weeks to months post-MI, autoimmune)
Cancer (primary or metastatic)
Autoimmune (e.g. rheumatoid arthritis, SLE)
Drug-induced (e.g. hydralazine)
Uraemic (end-stage renal disease)
Risk factors\:
Age\: average 41-60 years, advanced age risk for bacterial pericarditis
Sex\: higher in males
Seasons\: idiopathic cases more common in spring and fall
Steroids\: higher recurrence in patients on steroids
Bacterial pericarditis risk\: diabetes, extensive burns, systemic infections, immunosuppression, heart surgery, chest trauma,
pre-existing pericardial e
Symptoms\:
Chest pain (>90%)\: retrosternal, can radiate to neck, shoulders, arms; exacerbated by deep inspiration, relieved by sitting
forward
Dyspnoea
Clinical
Pericardial rub\: loudest at left lower sternal border, best heard leaning forward
Pericardial e
Beck’s triad (cardiac tamponade)\: hypotension, mu
Di
pathology, pneumothorax. Tamponade mimics\: decompensated heart failure, pulmonary hypertension conditions, right
ventricular MI.
Investigations\:
Bedside\: Basic observations (signs of shock), 12-lead ECG (widespread ST-elevation, PR depression, low voltage
QRS/electrical alternans in tamponade)
Laboratory\: FBC (raised WBC), CRP/ESR (raised), troponin (elevated with myocarditis), U&E (renal dysfunction), LFTs (liver
dysfunction)
Imaging\: Chest X-ray (cardiomegaly with e
(pericardial thickening, in
Management\:
Symptom relief\: NSAIDs (e.g. ibuprofen), colchicine (reduces recurrence), corticosteroids (second-line)
Treat underlying cause if identi
Lifestyle\: restrict physical activity until symptom resolution, safety netting
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Complications\:
Pericardial e
Recurrent/chronic pericarditis\: 15-30% recurrence, treated with immunosuppressants, IV immunoglobulins, IL-1 antagonists,
or pericardiectomy
Constrictive pericarditis\:
Article 🔍
A comprehensive topic overview

Introduction

Pericarditis refers to in
Pericarditis is more prevalent in men, predominantly in young adults. It is the most common disease of the pericardium
seen in clinical practice. Pericarditis makes up 0.1% of all hospital admissions and 5% of emergency department admissions
for chest pain.
Acute pericarditis has several potential causes, although in most cases it is idiopathic.
1

Aetiology

Anatomy

The pericardium is the outer lining of the heart and comprises of two parts, an outer
pericardium.
2
The
2
The serous pericardium consists of an outer parietal layer, which sticks to the inner surface of the
an inner visceral layer that attaches to the heart and forms the heart’s outer epicardium layer.
3
A small space exists between the parietal and visceral layers of the serous pericardium, called the pericardial cavity,
where a small volume of
freedom in heart movement and changes in shape.
3
Figure 1. The pericardium

Causes of pericarditis

Most cases of pericarditis are idiopathic, and an underlying cause is not found.
However, potential underlying causes of pericarditis include\:
4
Infections\: viruses (e.g. coxsackievirus and HIV), bacteria (e.g. staphylococcus and M y c o b a c t e r i u m t u b e r c u l o s i s ) and
fungi (e.g. histoplasmosis)
Acute myocardial infarction\: pericarditis occurs 1-3 days after an infarction involving the full thickness of the ventricular
wall (transmural). This is believed to be the result of the healing necrotic heart tissue interacting with the pericardium.
Dressler’s syndrome\: this form of pericarditis tends to occur weeks to months after myocardial infarction. It is an
autoimmune response triggering systemic in
Cancer\: primary tumours (e.g. mesotheliomas) or metastatic (e.g. from breast or lung cancers)
Autoimmune\: collagen or vascular disorders (e.g. rheumatoid arthritis, systemic lupus erythematosus)
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Drug-induced (e.g. hydralazine)
Uraemic\: from the accumulation of toxic metabolites and nitrogenous waste in the blood as seen with end-stage renal
disease

Risk factors

Risk factors for pericarditis include\:
5
Age\: the average age of patients with acute pericarditis is 41-60 years and advanced age is a risk factor for bacterial
pericarditis
Sex\: males have a higher risk for developing acute pericarditis
Seasons\: idiopathic pericarditis has been found to occur most often in the spring and fall
Steroids\: recurrent pericarditis occurs more often in patients being treated with steroids
Additional risk factors for bacterial pericarditis include\:
5
Diabetes
Extensive burn injuries
Systemic infections
Immunosuppression
Heart surgery
Chest trauma
Pre-existing pericardial e

Clinical features

History

Typical symptoms of pericarditis include\:
4
Chest pain (>90%)\: typically retrosternal but can be left-sided, radiating to the neck, shoulders and arms. Radiation to the
trapezius ridge is a classic sign. It can be exacerbated by deep inspiration (pleuritic) and when lying down, typically
relieved by sitting or leaning forwards.
Dyspnoea
Other important areas to cover in the history include\:
4
Systems review\: can identify clues related to the causative diagnoses such as recent infective symptoms or a known
autoimmune disorder
Drug history (e.g. chemotherapy drugs)
Travel history\: may reveal recent travel to countries endemic for certain infectious diseases

Clinical examination

A thorough cardiovascular examination should be performed to look for features of pericardial e
tamponade.
Typical clinical
4
Pericardial rub\: due to friction between the pericardial layers, typically loudest at the left lower sternal border, best heard
with the patient leaning forward
Evidence of pericardial e
breath sounds in the left axilla/base due to bronchial compression, obscured apex beat
Beck’s triad indicative of cardiac tamponade\: hypotension, muJVP
Cardiac tamponade
Patients with cardiac tamponade exhibit varying signs of decreased cardiac output and shock including
hypotension, tachycardia, tachypnoea, cool peripheries, diaphoresis and peripheral cyanosis.
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The y descent of the JVP is usually absent, as the heart volume becomes
Pulsus paradoxus may be present. This refers to an abnormally large drop in pulse pressure during inspiration
(≥10mmHg in systolic pressure).

Di

It is important to diacute coronary syndrome,
pneumonia with pleurisy, pulmonary embolism, gastro-oesophageal re
A detailed history is important to make this distinction as well as a thorough systems review. Investigations such as ECGs
and chest X-rays are also important for the exclusion of other di
Other less common di
Aortic dissection
Intra-abdominal pathology
Pneumothorax
Cardiac tamponade can be confused with conditions that cause shock, low blood pressure, raised JVP, including\:
6
Decompensated heart failure
Conditions causing pulmonary hypertension such as pulmonary embolism, chronic lung disease, coronary artery
disease, liver cirrhosis
Right ventricular myocardial infarction

Investigations

Bedside investigations

Relevant bedside investigations include\:
2
Basic observations (vital signs)\: to check for signs of shock such as hypotension and tachycardia
12-lead ECG\: typical
1
segment depression; low voltage QRS complexes/‘electrical alternans’ indicates signi
ECG changes re
Figure 2. ECG demonstrating the typical PR depression and concave shaped ST elevation in pericarditis
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Figure 3. ECG demonstrating electrical alternans with sinus tachycardia in cardiac tamponade

Laboratory investigations

There is no single diagnostic laboratory test for acute pericarditis. However, blood tests can help exclude other causes or
may give clues to the underlying aetiology or potential precipitating factors.
Relevant laboratory investigations include\:
1
Full blood count\: raised white blood cell count is a common
In
Troponin\: may be elevated if there is co-existent myocarditis
Urea and electrolytes\: for renal dysfunction
Liver function tests\: for liver dysfunction
Additional testing would be done if suspecting a speci
woman if there is suspicion of systemic lupus erythematosus.

Imaging

Relevant imaging investigations include\:
1
Chest X-ray\: often normal in acute pericarditis, a raised cardiothoracic ratio is typically associated with a pericardial
e
Transthoracic echocardiography\: performed to check for any evidence of e
to look for any signs of haemodynamic compromise as it the haemodynamic e
of the e
as an inpatient or if they can be managed as an outpatient.
Cardiac CT or MRI\: may be performed in atypical presentations to look for pericardial thickening and in
MRI may be performed in suspected myopericarditis as these patients have poorer long-term outcomes and require
additional drug treatment including ACE inhibitors or beta-blockers as well as follow up.
Figure 4. Chest x-ray showing signs of
pericardial e
of the heart).
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Management

After con
treatment is usually directed at alleviation of symptoms as acute idiopathic pericarditis is typically self-limiting in 70-90%
of patients.
If an underlying cause of pericarditis is found, management should involve treating the underlying condition.
General lifestyle advice for all patients includes restricting physical activity until symptoms have resolved and, for
athletes, it is recommended to return to sports after three months, only after symptoms have fully resolved and
investigation

Symptomatic management

Non-steroidal anti-in
on the patient’s history (e.g allergies, contra-indications or co-morbidities). For example, aspirin would be favoured if it is
already needed for antiplatelet treatment and patient preferences. Gastroprotection with a proton pump inhibitor should
be given as well.
Colchicine is recommended as an adjunct for three months. It has been shown to improve the response to medical therapy
and reduce recurrences by approximately 50% during follow-up.
Corticosteroids are second-line, for example, if there is a contraindication to or failure of NSAID and colchicine therapy.
Low doses are recommended to prevent complications and colchicine is given concurrently.

Predictors of poor prognosis

Major risk factors identi
1
o
Fever >38 C
Subacute onset
Large pericardial e
Cardiac tamponade
Failure of response to NSAIDs after a week of therapy

Complications

Pericardial e

Any disease leading to pericarditis can cause pericardial e
neoplastic conditions involving the pericardium (exudate). Pericardial
reabsorption because of a rise in systemic venous pressure from heart failure or pulmonary hypertension (transudate).
1
As an e
heart. It reaches a critical point when the e
reduced cardiac output. This compromise of ventricular
tamponade, a life-threatening emergency.
5
Treatment involves draining the pericardial
pericardial
4

Recurrent or chronic pericarditis

Approximately 15-30% of patients develop a recurrence of symptoms. This can be termed ‘incessant’ with symptoms
lasting for more than 4-6 weeks or ‘chronic’
, lasting for more than 3 months. This rate of recurrence may rise to 50% in
patients not given colchicine, especially if treated with steroids.
1
Novel treatment options now exist for refractory recurrent pericarditis, including immunosuppressants (such as
azathioprine), intravenous immunoglobulins and IL-1 antagonists (such as anakinra).
1
A potential alternative to giving further medical treatment is pericardiectomy (surgically removing part or all of the
pericardium).
1
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Constrictive pericarditis

This can be considered the
linked to the aetiology with the risk being highest in bacterial pericarditis. The most prevalent cause reported in
developed countries is idiopathic, viral, post-cardiac surgery or post-radiation.
1
In
pericardium. This scarring tends to be symmetric and if the pericardium becomes inelastic to a point where it hinders
diastolic
therefore it enables to body to compensate and is therefore not imminently life-threatening like cardiac tamponade.
5
For the majority of patients, the de
(resection of the pericardium).
2

References

Yehuda Adler, Philippe Charron, Massimo Imazio, Luigi Badano, Gonzalo Barón-Esquivias, Jan Bogaert, Antonio Brucato,
Pascal Gueret, Karin Klingel, Christos Lionis, Bernhard Maisch, Bongani Mayosi, Alain Pavie, Arsen D Ristić, Manel Sabaté
Tenas, Petar Seferovic, Karl Swedberg, Witold Tomkowski, ESC Scienti
diagnosis and management of pericardial diseases\: The Task Force for the Diagnosis and Management of Pericardial
Diseases of the European Society of Cardiology (ESC). Endorsed by\: The European Association for Cardio-Thoracic Surgery
(EACTS), E u r o p e a n H e a r t J o u r n a l , Volume 36, Issue 42, 7 November 2015, Pages 2921–2964
Susan Standring. Gray’s Anatomy. 42 nd
Elsevier. Published in 2020.
Amar Vaswani, Hwan Juet Khaw, Scott Dougherty, Vipin Zamwar, Chim Lang. Cardiology in a heartbeat. Scion Publishng
Limited. Published in 2016.
Parveen J. Kumar, Michael L. Clark, Adam Feather, David Randall, Mona Waterhouse. Kumar and Clark's Clinical Medicine.
Tenth Edition. Elsevier. Published in 2020.
Hessen et al. Elsevier Point of Care. Clinical overview. [Updated 2021 Jul 20].
Douglas P. Zipes, Peter Libby, Robert O. Bonow, Douglas L. Mann, Gordon F. Tomaselli, Eugene Braunwald. Braunwald's
Heart Disease\: A Textbook of Cardiovascular Medicine, Eleventh Edition. Published in 2018.

Image references

Figure 1. Blausen Medical Communications Inc. (2013). License\: [CC BY 3.0]
Figure 2. James Heilman, MD (2011). License\: [CC BY-SA 3.0]
Figure 3. James Heilman, MD (2011). License\: [CC BY-SA 3.0]
Figure 4. HellerhoCC BY-SA 3.0]

Reviewer

Dr Kuldeepa Veeratterapillay
Cardiology Registrar

Related notes

Acute Coronary Syndrome (ACS)
Acute Heart Failure
Atrial Fibrillation (AF)
Atrioventricular Block
Brugada Syndrome
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Test yourself

Contents

Introduction
Aetiology
Risk factors
Clinical features
Di
Investigations
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