Today we discussed pericarditis. A few key points:
Causes of pericarditis:
Vast majority are viral/idiopathic (90%).
Long list of other causes includes
-other infections (purulent pericarditis- H.Flu, pneumococcal, many others), TB
-aortic dissection, trauma
-uremia
-malignancy (although more commonly effusion than pericarditis)- breast, lung, esophageal, hematologic malignancies
-primary autoimmune of inflammatory disorders (esp. SLE, RA, mixed CTD, many others)
-post radiation
-drugs
Pain in pericarditis is usually retrosternal, acute onset, and pleuritic. Often worse supine, improves leaning forward
Physical exam may show pleural rub (mono, bi, or tri-phasic)- each phase corresponds to movement of pericardium. Triphasic rub has 2 diastolic components (early and late diastolic filling) and 1 systolic component. Differentiate pleural vs. pericardial rub by having pt stop breathing. Also look for signs of effusion and tamponade or constrictive pericarditis- JVP findings, pulsus paradoxus, etc.
ECG in pericarditis: 4 stages described
1) diffuse ST elevation (concave up; not dome-shaped) and PR depression
2) normalization of ST and PR changes
3) diffuse T-wave inversions
4) normalization of T changes
ECG in pericarditis vs. MI: In MI, uncommon to have diffuse STE, concave up ST segments, PR depression. T-inversions in MI usually happen before ST segments return to baseline (as opposed to above sequence).
Poor prognostic factors- consider 2D echo +/- admission:
-fever
-subacute onset
-immunosuppression
-trauma-associated
-anticoagulation
-elevated troponin (implies myocardial involvement)
-tamponade suspected (no kidding...)
Every pt should have CBC, troponin., Other tests are guided by evaluation.
Treatment:
If no specific cause found (majority of cases), options include
-high dose ASA (2-4g/day)
-ibuprofen (1600-3200mg/day) or other high dose NSAID
In recurrent pericarditis, colchicine or prednisone are often effective.
Complications of pericarditis:
-cardiac tamponade
-constrictive pericarditis
Link:
Click here for a NEJM review of pericarditis
Click here for JAMA Does this patient have cardiac tamponade?
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