Pericarditis

Second line therapy

• Steroids
• Connective Tissue dz.
• TB pericarditis
• Unresponsive to NSAIDS

Other considerations

• Pericardialcentesis
• Window

Colchicine

0.6mg BID x 3 mos (6

mos in reoccurence)

*Only med in RCT shown

to improve # of

recurrence

Treatment

• NSAIDS: (first line)
• Ibuprofen 600mg TOD x 1-2 weeks (2-4 for recurrence) then taper
• ASA 750mg-1gm for 1-2 week (2-4 recurrence) *perfer in MI other NSAIDs impair scar formation
• Indomethacin: 50mg TID 1-2 wks (2-4 recurrence) *Avoid in elderly
• Toradol 15mg-30mg (inpatient)
• **Think GI prophylaxis; Taper when inflamm markers down
• **Use in caution with PUD

Diagnostics (cont'd)

EKG in pericarditis

• Stage 1: diffuse ST elevation,

PR segment depression

• Stage 2: Normalization of ST and PR segments, T wave flatten and invert
• Stage 3: Widespread T wave inversions
• Stage 4; Normalization of T waves,

may have persistant inversions if

chronic pericarditis

Physical exam

• Initial testing:
• Labs:
• CBC can show leukocytosis
• ESR, CRP, LDH
• Cardiac biomarkers
• Can be elevated in younger patients, males
• EKG: widespread EKG elevation (see next slide)
• TTE (eval for effusion)
• CXR r/o pulm issues
• CT/MRI

• HR: regular or rapid
• Pericardial friction rub:
• coarse, high pitched
• end-expiration
• LLSB
• *Lean patient fwd.
• rub may be transient
• New S3 may suggest myopericarditis
• Cardiac tamponade

Diagonstics:

(two to four criteria)

• Typical pleuric CP
• Pericardial friction rub (33%)
• Ekg non-regional ST elevations (60% of cases)
• New/increasing pericardial effusion.

Risk factors/History

*Risks: Thoracic surgery, CKD, PNU, Autoimmune disease, Lung/Breast CA

*History:

• Prodrome: fever, malaise, myalgias, URI
• Acute, sharp, stabbing CP
• Lasting hours-days
• Pleuritic type CP
• "better leaning forward, worse with lying flat."
• SOB

Types of Pericarditis

What is it?

*Inflammation of the pericardium

*May have or may not have associated pericardial effusion.

*May also include the myocardium AKA: Myopericarditis or Perimyocarditis

*Anatomy Review:

Idiopathic

• 85-90% of cases
• Viral infection --> to immune response

Infectious

• Viral
• EBV,HIV, MM, Varicella.
• Bacterial: Mycobacterium TB
• Fungal:
• More common in the immunocompromised
• Parasites:

Non-infectious

• Acute MI (2-4 days later), Dresseler syndrome (weeks-months after MI)
• Ao Dissection
• Renal Failure/Uremia
• Malignancy
• Radiation therapy
• Trauma
• After cardiac procedures
• Autoimmune DO.
• Med related

Follow up.....

• 7-10 days to respond to therapy
• 1 month to check labs
• For myopericarditis: Use low dose of anti-inflammtoary
• 4-6 weeks of exercise restriction
• Follow up echo (1,6,12 mos)

How frequent is it?

*Exact incidence unknown

*Should be included in differentials in c/o chest pain; given about 5% of ED "Chest Pain" not related to MI can be associated with pericarditis.

*Men > Women

*After first episode up to 30% patients will have recurrence within the next 18 months.

Tell me more..

* Pericarditis = inflammation of the pericardial sac

• acute
• chronic ( >3 mos)
• recurrent (additional episode 4-6 weeks after symptoms disappear in first episode). Chronic or recurrent episodes can cause restrictive pericarditis

Pericarditis