Pericardial Disease Acute Pericarditis
Etiology
Idiopathic, neoplastic (chemotherapy and radiation), autoimmune, viral, tuberculosis, bacterial (nontuberculous), uremia, post-cardiac surgery, trauma, post-myocardial infarction, drugs, dissecting aortic aneurysm, hypothyroidism.
Pathophysiology
• The pericardium is a fibrous sac surrounding the heart consisting of two layers: a thin visceral layer attached to the myocardium and a thicker parietal layer.
• The pericardial space is normally filled with 15-50 mL of fluid, and the two layers slide smoothly against each other, allowing for normal expansion and contraction of the heart.
• Pericarditis occurs when these layers are inflamed.
DIAGNOSIS
History
• The clinical presentation of acute pericarditis can vary depending on the underlying etiology.
• Chest pain: typically sudden onset, anterior chest, sharp and pleuritic; improved by sitting up and leaning forward, made worse by inspiration and lying flat, radiation to back, neck and shoulders, pain along the trapezius ridge.
Physical Examination
Pericardial friction rub: highly specific for acute pericarditis. Described as a “scratchy, grating, or squeaking sound,” heard best with the diaphragm of the stethoscope.
Diagnostic Testing
• Electrocardiogram (ECG): diffuse ST-segment elevation (usually in more than one coronary artery distribution) and PR depression.
• Transthoracic echocardiogram (TTE): may observe an associated pericardial effusion.
• Other tests: complete blood count, C-reactive protein, erythrocyte sedimentation rate, blood cultures (if suspect infection), thyroid function, cytology (if suspecting neoplasm).
TREATMENT
• Treat the underlying cause whenever possible.
• NSAIDs: ibuprofen, aspirin, ketorolac.
• Colchicine: when added to conventional anti-inflammatory therapy, significantly reduces symptoms, recurrence rates, and hospitalizations (COPE trial).1
• Glucocorticoids: reserved for cases refractory to standard therapy or in the setting of uremia, connective tissue disease, or immune-mediated pericarditis. Increases risk of recurrence.