# 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
PDF coming soon!
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.