Makindo Medical Notes.com

Related Subjects: |Assessing Breathlessness |Assessing Chest Pain |Pericardial Effusion and Tamponade |Constrictive Pericarditis |Colchicine

ST changes in pericarditis are widespread over multiple areas. ST changes are concave "saddle shaped". May be peaked T waves and widespread PR depression

Epidemiology

• 5% of emergency room admissions for chest pain
• 5% develop tamponade or constrictive pericarditis

Clinical

• Fever, sweats, malaise, myalgia
• Pleuritic chest pain worse with inspiration and cough.
• Pleuritic Pain is positional - improves sitting up and forwards.
• Audible friction rub with three components - atrial systole, ventricular systole and diastole.
• There may be a squeaky sound at left sternal border
• Distant heart sounds may suggest effusion

Assess for clinical evidence of tamponade with distended neck veins, pulsus paradoxus either palpable or >10–15 mmHg by blood pressure cuff and hypotension

Differential Diagnosis for Chest pain

• Acute coronary syndrome, Myocarditis, Aortic Dissection,
• Pneumonia, Pneumonitis, Pulmonary embolism,
• GORD and oesophageal disease, Musculoskeletal

Causes

• Idiopathic/Post viral, MI or Post MI - Dressler's syndrome,
• Post pericardiotomy, Infectious: bacterial, viral, fungal, HIV,
• Malignancy, Metabolic - uraemia, dialysis
• Autoimmune: Dressler syndrome, Systemic Lupus Erythematosus
• Familial Mediterranean fever, Trauma/Radiation, Drugs
• Aortic dissection , Congenital

Investigations

• Bloods: FBC, U&E, LFT, ↑ CRP ↑ ESR
• ECG: Widespread ST-segment elevation has been reported as a typical hallmark sign of acute pericarditis. Changes in the ECG imply inflammation of the epicardium. Changes evolve with time (1) saddle ST elevation in most leads. Depression in aVR. PR segment depression except elevated in aVR (2) ST/PR changes resolve (3) widespread T wave inversion (4) T wave changes resolve. The differential involves STEMI and early repolarisation.
• ↑CRP ↑ ESR: elevated if inflammatory/infective process and can help guide therapy.
• ↑ CK ↑ Troponin: elevation suggests an associated mild myocarditis. This is often termed myopericarditis.
• CXR: Generally normal. Effusion with cardiomegaly
• Echocardiogram: 60% may have a pericardial effusion. Rarely tamponade

ECG showing Generalised Saddle shaped ST elevation in all leads other than AVR

Predictors of Worse Prognosis

• Major
  • Fever > 38
  • ↑ CRP
  • Subacute onset
  • Large pericardial effusion
  • Cardiac tamponade
  • Lack of response to Aspirin or NSAIDS after 1 week of treatment
• Minor
  • Myopericarditis
  • Immunosuppression
  • Trauma
  • Oral anticoagulant

Management

• Most cases are idiopathic or viral and self-limiting and settle in 2-6 weeks and can be managed through ambulatory service. Severe complications are uncommon in idiopathic recurrent pericarditis. Cardiac tamponade is rare and generally occurs at the beginning of the disease.
• For those with elevated cardiac markers and a diagnosis of myopericarditis the myocardial involvement in pericarditis has a good prognosis, and several observational series have demonstrated no evolution to heart failure or mortality in patients with myopericarditis
• Exercise restriction: athletes are recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG and echocardiogram) have been normalized. Some advice waiting 3 months.
• Consider admission if
  • Non-viral cause
  • Fever > 38 C
  • Effusion > 20 mm
  • Tamponade
  • Traumatic
  • Immunosuppressed
  • On Anticoagulants
• NSAIDS: may be useful. e.g. Ibuprofen 400-600 mgs TDS for 1-2 weeks with PPI. Analgesic and anti-inflammatory.
• Colchicine: Acute and recurrent Pericarditis: Colchicine 1 g/day if > 70 kg and 0.5 g/day if under 70 Kg. Given for 3 months under expert review. Steroids: more severe cases.
• Anticoagulant risk: Assess risk-benefits for anticoagulants. Potential risk of bleeding into pericardial space.
• Infection: Treat TB with 4 drug anti TB therapy, Bacterial consider antibiotics and Fungal infections needs systemic antifungals.
• Neoplasia: consider chaemotherapy

References

• 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)