inpatient / Cardiology


Last Updated: 1/23/2023

# Pericarditis 2/2 ***
Acute <6w, Chronic >6mo

-- ABCs: 
is there any evidence of tamponade (Beck Triad - hypotension, muffled heart signs, distended neck veins or JVP), ACS, or other life-threatening causes of chest pain?
-- Chart Check: previous echos, h/o MI, malignancy, autoimmune disease, radiation
-- Admission Criteria: patient fevering, elevated WBC c/f infection, large effusion >2cm, c/f tamponade physiology, increased trop, immunocompromised
-- HPI Intake: symptoms (pleuritic CP, fatigue, DOE); timing, recent or current infections, previous MI, cancer screening, prev radiation, FHx autoimmune dx
-- Can't Miss: missed MI, ongoing tamponade
-- Admission Orders: EKG, CXR, TTE; CBC, BMP, ANA/RF/CCP, HIV, IGRA, ESR/CRP, trop, RVP if sxs
-- Initial Treatment to Consider: NSAIDs if no contraindications, otherwise pred; add colchicine if with 72 hours

-- History: *** timing, infections, previous MI, cancer screening, prev radiation, FHx autoimmune dx
-- Clinical: *** pleuritic CP, fatigue, DOE, relieved by sitting up and leaning forward, viral sxs
-- Exam: *** friction rub (30% of cases) best heard end-expiration when leaning forward, volume (JVP, Kussmaul sign, edema), pulsus paradoxus
-- Data: *** EKG (diffuse ST elevations 2/2 epicardial inflammation), echo, CXR, trop, creatinine, BUN
-- Etiology/DDx: *** viral/post-viral, bacterial, post-MI, uremic, autoimmune, malignancy, radiation

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- f/u EKG, CBC, BMP, troponin, ESR/CRP; send ANA/RF/CCP, HIV if uncertain etiology
-- f/u infectious w/u including RVP is sxs
-- Trend EKG
-- TTE for initial effusion size with plan to repeat in 4-6 weeks

-- NSAIDs until sxs resolve (often one month, then taper) - ibuprofen 600-800mg TID or ASA 650-1000mg TID (ASA preferred in post-MI, CAD, if pt also on anti-platelet or AC) 
-- Colchicine if within 72 hours (for 3 months) - 0.6mg BID (daily if <70kg)
-- Prednisone (2 weeks, then taper) - 0.2-0.5 mg/kg/day if refractory to NSAID for 7d, contraindication to NSAIDs, recurrent episodes, uremic pericarditis, CTD
-- Consider PPI for gastroprotection if on NSAIDs or steroids if risk of GI bleed (prior bleed, PUD, on AC)
-- Pericardiocentesis if: c/f malignancy or bacterial, large effusion (>2cm), tamponade
-- Guidance: restrict physical activity until sxs resolve and EKG and CRP have normalized

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If You Remember Nothing Else

Pericarditis is a cause of atypical chest pain that usually resolves in its own, but can create serious complications include tamponde physiology. Viruses are the most common etiology, and this process will be self-limited. Classic teaching for tells us to look for the Beck Triad (hypotension, muffled heart signs, distended neck veins) to assess for tamponade physiology 2/2 constrictive pericarditis, but this may not be sensitive since all three are rarely found together. NSAIDs/ASA are the preferred treatment if there is no contraindication, and colchicine can be added if done early in the disease process. Steroids should be added only in severe disease, NSAIDs are contraindiated, or if the etiology is uremia or autoimmune. In general, NSAIDs and steroids should be avoided in the post-ACS setting, as they can impair healing of the infarct.

Clinical Pearls

  • Among patients who present to the ED with chest pain who DO NOT have ACS, 5% end up being diagnoses with pericarditis
  • EKG - diffuse ST elevations (epicardial inflammation) → resolution in 1 week → TWI → resolution in weeks to months
  • Most cases are self-limited and resolve within days to weeks
  • Most commonly a viral etiology - coxsackie B virus
  • The feared complication of pericarditis is constrictive pericarditis leading to tamponade - tamponade can occur with small effusions, and is more based on the timing of accumulation and the ability of the body to adapt; also be careful with positive pressure ventilation if concerned about constrictive pericarditis
  • Postinfarction inflammation happens with within 1-3 days vs Dressler syndrome seen in weeks-months - Dressler is autoimmune radiated (more likely to see fever, leukocytosis) and is very rare;  avoid NSAIDs in immediate post-ACS setting - increased risk of repeat MI and bleeding in patients with CAD
  • A pericardial friction rub is friction between visceral and parietal pericardial tissue - best heard on the left sternal border, during expiration while sitting up and leaning forward
  • Kussmaul sign - JVP elevated on inspiration due to decreased compliance of right heart
  • Pulses Paradoxus - decrease in BP amplitude by 10 during inspiration - more indicative of tamponade physiology than pericarditis
  • Colchicine is best if given early and not sure of etiology - no benefit for malignant or uremic pericarditis
  • The major side effects of colchicine are diarrhea (8.3% of cases) but not really at much higher rates than just NSAID alone, and is rapidly reversible when stopped
  • Giving steroids increased the risk of recurrence at 18 months in the COPE trial (33.3% vs 10.7%) - possibly deleterious if given in a viral infection

Trials and Literature

  • COPE Trial - in first-time pericarditis - ASA vs ASA + colchicine - improved recurrence at 18 months (10.7% vs 36.7%) (Circulation, 2005)
  • ICAP Trial - in first-time pericardiits - NSAID vs NSAID + colchicine - reduced rate of symptoms at 72 hours (5.0% vs 14.2%), remission rate at 1 week (85% vs 58.3%) (NEJM, 2013) 
  • Does This Patient with a Pericardial Effusion Have Cardiac Tamponade? Rational Clinical Exam (JAMA, 2007)

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