Tuesday, July 10, 2012

Pericarditis




Today we discussed the case of a man with pericarditis. 

See here for a discussion of the causes of pericarditis.

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 corresponds to three stages: atrial systole, ventricular systole and ventricular diastole.  Also look for Kussmaul's sign (suggests constrictive pericarditis) and signs of tamponade: JVP findings, pulsus paradoxus.

ECG in pericarditis vs. MI: In MI, uncommon to have diffuse STE however could happen if large antero-inferior infarct. The key differences are: in pericarditis have concave up ST segments, lack of reciprocal changes, only ST depression is avR (rather than avL in inferior MI), PR depression, T-inversions only occur once ST segment returns to baseline (unlike in MI).

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.

Link:
Click here for a NEJM review of pericarditis
Click here for JAMA Does this patient have cardiac tamponade?

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