Pericarditis – Quick Consult
Last Updated / Reviewed: 4/5/2021

Causes of Pericarditis
Key History
Key Physical Exam
Risk Factors for Pericarditis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications 

Causes of Pericarditis

  1. Idiopathic – most common cause of acute pericarditis
  2. Infectious
    1. Viral – second most common cause acute pericarditis. Peak occurrences in fall and spring.
    2. Bacterial – causes purulent pericarditis
    3. Tubercular – 4%
    4. Fungal
    5. Parasitic
  3. Inflammatory
    1. Rheumatoid arthritis
    2. Systemic lupus erythematosus
    3. Scleroderma
    4. Rheumatic fever
    5. Sarcoidosis
  4. Other
    1. Sjögren’s syndrome
    2. Ankylosing spondylitis
    3. inflammatory bowel disease
    4. Reiter syndrome
    1. Behçet’s disease
    2. Whipple’s disease
    3. Familial Mediterranean
    4. Fever
    5. Serum sickness
    6. Vasculitis
    7. Wegner’s granulomatosis
    8. Mixed connective tissue disease
  1. Metabolic
    1. Uremia/renal failure 12%
    2. Hypothyroidism 4%
    3. Cholesterol pericarditis
  2. Cardiovascular disease
    1. Myocardial infarction
    2. Dressler’s syndrome
    3. Aortic dissection
  3. Neoplasm between 5%-17%
  4. Iatrogenic
    1. Drugs
    2. Irradiation
    3. Post pericardiotomy syndrome
  5. Trauma
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Key History

  • Chest pain is often precordial
  • Chest tightness
  • Cough
  • Fever
  • Myalgia
  • Pain improved by leaning forward.
  • Pain worsens with movement, laying flat, and on inspiration.
  • Pain may be abrupt in onset.
  • Pain may radiate to trapezius area.
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Key Physical Exam

  • Friction rub heard best over left lower sternal border.
  • Tachycardia
  • Tachypnea
  • Rales
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Risk Factors for Pericarditis

  • Infections:
    • Viral – Coxsackie B, echovirus, influenza virus, HIV, enterovirus, measles, mumps, EBV, VZV, parainfluenza 2, and RSV. Coxsackie B and influenza tend to occur seasonally.
    • Bacterial – Staphylococci, streptococci, haemophilus, pneumococcus, proteus, pseudomonas, salmonella, shigella, meningococcus, Lyme disease, legionella, mycoplasma
    • Fungal – Blastomycosis, coccidioidomycosis, nocardia, candidiasis, and histoplasmosis
    • Parasitic – Toxoplasmosis, amebiasis, echinococcosis
  • Autoimmune disorders: SLE, RA, sarcoidosis, scleroderma, acute rheumatic fever, and others
  • Malignancy
  • Post pericardiotomy
  • Post MI (Dressler’s syndrome)
  • Trauma
  • Uremia
  • Myxedema
  • Radiation
  • Drugs: Hydralazine, isoniazid, procainamide, methysergide, phenytoin, bleomycin, minoxidil, mesalamine or azathioprine
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Differential Diagnosis

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Diagnostic Testing

Text / literature information and recommendations include:

  • Patients suspected of having pericarditis should have ECG, CSR, echocardiography, WBC, ESR and/or C-reactive protein. Select patients should have a HIV serology, TB skin testing, and ANA.
  • The 2015 European Society of Cardiology (ESC) guidelines state that the diagnosis of acute pericarditis can be made with at least two of the following four criteria:

    • Pericarditic chest pain
    • Pericardial rub
    • New widespread ST segment elevation or PR depression
    • New or worsening pericardial effusion
    Supporting findings can include elevation of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, white blood cell count), and evidence of pericardial inflammation on imaging (computed tomography [CT], cardiac magnetic resonance [CMR]).

  • ECG findings in acute pericarditis:
    • Stage 1 – Diffuse ST segment elevation with a decreased PR segment
    • Stage 2 – Flattened T waves
    • Stage 3 – Decreased/flattened T waves
    • Stage 4 – Normal
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Clinical Risk and Safety Pearls

  • Features associated with higher risk of complications include:
    • High fever and leukocytosis
    • Evidence suggesting tamponade
    • Large pericardial effusion
    • Acute trauma
    • Subacute symptoms
    • Immunosuppressed state
    • History of anticoagulant therapy
    • Failure to respond to 7 days NSAID therapy.
  • Patients with any high-risk features above should be admitted.

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Treatment

Common text / literature recommendations include:
  • Identify cause if possible, treatment of the underlying disorder if indicated.
  • No therapy has been proven to prevent serious sequela in acute viral or idiopathic pericarditis.
  • Stop causative drugs.
  • Consider pericardiocentesis if:
    • Moderate to severe tamponade is present.
    • Purulent, tuberculous, or neoplastic pericarditis is suspected.
    • A persistent symptomatic pericardial effusion is present.
  • Per the ESC 2015 Guidelines: Aspirin (750–1000 mg every 8 hours for 1–2 weeks) or NSAIDs (ibuprofen 600 mg every 8 hours for 1–2 weeks) with gastric protection are recommended as first-line therapy for acute pericarditis. Colchicine (0.5 mg daily [<70 kg] or BID [≥70 kg] for 3 months) is recommended as first-line therapy as an adjunct to aspirin/NSAID therapy.
  • Corticosteroids should be considered only if the patient is clearly refractory to NSAIDs and colchicine, and a specific cause for the pericarditis has been excluded. Not a decision likely to be made in the emergency department.
  • Bacterial, purulent, tuberculous pericarditis must be treated with antibiotics and may need surgical drainage.
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Complications

  • Tamponade
  • Recurrent pericarditis

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  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964.
  2. Imazio M, Gaita F. Acute and recurrent pericarditis. Cardiol Clin. 2017;35(4):505-513.
  3. LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014;371(25):2410-2416.
  4. Maisch, B, Seferovic, PM, Ristic, AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25:587.
  5. Niemann J. Cardiomyopathies and Pericardial Disease. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.

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