Definition

Inflammation of the pericardium due to infection with a viral, rickettsial, bacterial, chlamydial, or fungal organism or from a noninfectious cause. Pericardial effusion involves the accumulation of fluid in the pericardial space. The fluid accumulation is composed of transudate, exudate, serosanguinous fluid, or frank blood.

History

Management considerations should involve self-monitoring of the patient’s blood pressure at home, use of a low-salt diet, and strict abstinence from smoking and alcohol. If the diastolic is consistently 99 mmHg or greater, an antihypertensive medication should be utilized. Methyldopa (Aldomet) is one medication that is recommended.

Symptoms: Severe, constant anterior chest pain is the most frequent complaint in acute pericarditis. Inspiration tends to worsen the pain and can help distinguish between pericarditis and acute myocardial infarction. The pleuritic pain can be referred to the neck and shoulder. The pain can also be intensified by movement and with swallowing. The onset of chest pain is typically sudden and is often accompanied by a low grade fever and a rapid heart rate. The patient may indicate that the pain is relieved by sitting and leaning forward.

General: A history of upper respiratory infection or gastrointestinal illness 2 to 3 weeks prior to the onset of chest pain should be elicited.

Age: Variable.

Onset: Chest pain of gradual to sudden onset depending on the underlying cause (e.g., viral, tuberculosis, neoplastic, uremic, radiation).

Duration: In general, symptoms of pericarditis resolve in 2 to 6 weeks. If effusion is present, surgical intervention may be necessary to achieve relief.

Intensity: Chest pain can be acute, constant, and severe.

Aggravating Factors: Deep inspiration will often aggravate chest pain.

Alleviating Factors: Sitting and leaning forward may relieve chest discomfort.

Associated Factors: Viral pericarditis is often preceded by an upper respiratory infection or gastroenteritis.

Physical Examination

General: The patient may be in significant distress, low-grade fever may be present. Obtain vital signs.

Cardiovascular: A pericardial friction rub is the classic finding in acute pericarditis. The triphasic rub can be heard with one systolic component as the ventricles contract and two diastolic components. The early diastolic sound, corresponds with ventricular filling and a late diastolic sound corresponds with atrial contraction. The sounds are typically rough, scratchy, and high pitched. Although variable in location, the rub can often be best heard with the diaphragm of the stethoscope at Erb’s point (third left intercostal space). The intensity is also variable, but the rub may be enhanced when the patient exhales while leaning forward. The rub will decrease or resolve if a pericardial effusion develops. If the effusion creates enough pressure to cause a cardiac tamponade, cyanosis may develop along with distention of the neck veins and dyspnea. If a constrictive pericarditis develops, the patient can demonstrate a pericardial “knock” that can be heard in diastole with a limitation of ventricular filling due to the constriction. Often accompanied by an elevated venous pressure and distended neck veins.

Pathophysiology

Viral agents are most often implicated in acute pericarditis and include enteroviruses (coxsackie viruses A and B) and echovirus. Other viruses occasionally found, include influenza, mumps, varicella, and EpsteinBarr virus. Tuberculosis is often present in exudative pericarditis but is much less common. Rare causes include fungi, mycoplasma, rickettsiae,

chlamydiae, protozoa, and Legionella pneumophilla. Often, especially in younger patients, an etiologic agent cannot be isolated. These cases are referred to as idiopathic or nonspecific pericarditis. Connective tissue disease such as systemic lupus erythematosus and rheumatoid arthritis can include pericarditis as part of the clinical picture.

A portion of the parietal pericardium is pain sensitive where it is in close approximation with the parietal pleura at the anterior and lateral borders of the heart. The parietal pleura is also pain sensitive and thus would account for the pleuritic nature of the pain associated with acute pericarditis. The pericardium is served by the fibers from the T6 dermatome band originating from T1 to T6, which runs from the neck to below the xyphoid process. The TI dermatome also runs down the arms. Lesions in the organs supplied by these fibers typically give rise to poorly localized pain that can radiate to the neck or shoulder. Pericardial effusion can result as a complication of acute pericarditis with any of the infecting organisms. It can also result from CHF, over hydration, hypoproteinemia, and neoplastic diseases. Additionally, effusion frequently accompanies uremic, radiation induced and idiopathic pericarditis. Bleeding into the pericardial space from trauma, myocardial infarction with rupture, and aortic aneurysm or bleeding induced by a coagulation defect can also cause a pericardial effusion. The amount of fluid present in the pericardial space and the intrapericardial pressure do not correlate well. In acute cases, as those associated with trauma, a small amount of fluid can lead to cardiac tamponade; whereas a large volume accumulated over an extended period of time can be well-tolerated.

Diagnostic Studies

The diagnosis of pericarditis is generally presumptive, however, certain classic findings can be useful.

Laboratory

Viral cultures: Should be done on samples taken from the pharynx and fecal material.

Acute and convalescent antibody titers: On the isolated virus. A four-fold increase is confirmatory.

Radiology

CXR: Will show an enlarged cardiac silhouette if effusion is present.

Other

ECG: With pericarditis will show widespread elevation of the S-T segment in leads beyond those used for isolation of myocardial infarction without the characteristic reciprocal S-T segment depression.

Echocardiography: Is confirmatory, and is a sensitive, noninvasive modality to detect fluid in the pericardial space.

Pericardiocentesis: Performed for cardiac tamponade. Gram stain and culture of the fluid is performed.

Differential Diagnosis

Traumatic

Myocardial contusion: Presents with persistent pain and antecedent trauma.

Costrocondritis: Point tenderness to palpation. ECG negative.

Infectious Pneumonia: CXR will show infiltrate. ECG negative.

Metabolic

Myocardial infarction:

Elevation of the S-T segment with reciprocal S-T segment depression. Positive cardiac isoenzymes.

Cholecystitis: Pain associated with fatty foods,. ECG negative. Ultra sound of gallbladder positive.

Neoplastic Chest wall/lung tumor: ECG negative. CXR positive.

Vascular

Pulmonary embolus: Significant dyspnea. VQ scan positive.

Congenital: Not applicable.

Acquired

Psychogenic chest pain: All diagnostic studies are negative.

Treatment

Viral Pericarditis

The illness generally follows a benign, self-limited course over 3 to 6 weeks. The aim of treatment is to reduce symptoms. Analgesic and anti inflammatory medications along with bed rest are the mainstay of therapy. Effusion usually does not develop, however, monitoring for signs of effusion and tamponade (e.g., neck vein distention, distant heart sounds, decreased arterial pressure, and dyspnea) and treatment, if necessary is appropriate.

Pericarditis With Purulent Effusion

Drainage of the pericardial fluid via pericardiocentesis or open surgical procedure is essential. Antimicrobial therapy is dictated by Gram stain and culture results. Infection of the pericardium with tuberculosis can present acutely with pericardial effusion with serosanguinous fluid and symptoms of tamponade or can evolve slowly over time and result in a constrictive pericarditis. Therapy would be the same as that instituted for pulmonary tuberculosis. Surgical intervention may be necessary to free the constriction by stripping both layers of the pericardium.

Non Infectious Pericarditis

Treatment or control of the underlying condition, if possible, is mandatory.The damage from trauma to the chest must be effectively managed emergently. Pericarditis in a patient with uremia would require dialysis to control the underlying edema and possibly pericardiocentesis and anti inflammatory therapy.

Radiation induced pericardial effusion can evolve into a constrictive pericarditis. Effusions due to neoplastic disease, systemic lupus erythematosus, and rheumatoid arthritis require treatment of the primary problem.

Recurrent Pericardial Effusions

Occasionally, treatment of the pericardial space with a sclerosing agent to cause the two surfaces of the pericardial sack to adhere to each other is indicated to prevent relapse. However, a complication of this procedure is constriction.

Pediatric Considerations

Pericarditis may occur in children of any age and is potentially life-threatening. Pericarditis in infants often has a viral etiology. Rheumatic fever is the most common cause of pericarditis in children. Other causes include bacterial infections, tuberculosis, cardiac surgery (postpericardotomy syndrome), or secondary treatment with chemotherapeutic agents. Symptoms may include signs of systemic infection, chest pain, and CHF. Management is dependent on the etiology and is generally the same as in adults.

Obstetrical Considerations

The use of NSAIDs should be undertaken with caution and only when clearly indicated if used in the treatment of pericarditis. Some of these drugs pose risks to the fetus that are similar to the side effects possible in the patient who is taking the NSAID. NSAIDs should not be used late in pregnancy due to the risk of premature closure of the patent ductus arteriosus in the fetus.

Tagged under:atrial contraction Cardiology gallbladder gastroenteritis hypoproteinemia pericardial effusions pericarditis pericarditis treatment pericardium

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