Acute pericarditis is defined as acute inflammation of the pericardium and is clinically characterized by chest pain, fever, tachycardia and pericardial friction rub. It has characteristic electrocardiographic (ECG) changes. It is more common in men.
Etiology
a) Idiopathic: Most common cause, though many of these cases could be of viral etiology.
b) Viral: The Coxsackie B and Echovirus are most common pathogens.
c) Purulent: Purulent pericarditis due to staphylococci, pneumococci or strephtococci can occur.
d) Tuberculous: Tuberculosis can infect the pericardium resulting in tuberculous pericarditis.
e) Pericarditis in acute myocardial infarction: Transmural myocardial infarction can cause pericardial inflammation in 12 – 15 per cent of cases. It is more often detected in anterior wall myocardial infarction and inferior wall with right ventricular infarction. With the widespread use of reperfusion therapy, the incidence of pericarditis in acute myocardial infarction has significantly come down.
f) Uremic: Uremic patients can develop pericarditis.
g) Neoplastic: Malignant tumours especially of lung and breast and lymphomas can involve the pericardium leading to pericarditis with effusion.
h) Collagen Disorders: Collagen disorders like lupus erythematosis, rheumatic fever and rheumatoid disease can cause pericardial inflammation.
i) Dressler’s Syndrome: Occurs 2 weeks to 2 years after acute myocardial infarction. The exact cause of Dressler’s syndrome is not clear, though proposed to be autoimmune in nature.
j) Post pericardiotomy Syndrome: Occurs 6 to 8 weeks after cardiac surgery. Thought to be autoimmune in mechanism.
k) Rare infecting organisms: Rarely fungal, rickettsial, spirochetal and parasitic infections can lead to pericarditis.
l) Traumatic: Traumatic perforation of the pericardium during procedures like pacemaker insertion, catheter ablation for arrhythmias or interventional procedures or pericardial perforation from penetrating chest injury or oesophageal perforation can cause pericardial
inflammation.
m) Radiation: Radiation to the chest can cause pericardial inflammation.
n)Other metabolic causes: Myxoedema and gout can also cause pericarditis.
Clinical PresentationSymptoms
Chest Pain
Chest pain is the most important symptom. It is retrosternal in location and patient usually locates the site of the pain without difficulty. The pain is severe and sharp and may radiate to the shoulder region and back. The pericardial pain increases on deep inspiration, coughing,swallowing and lying supine. Pain may be alleviated with patient sitting up and leaning forwards.
Fever
Fever is a feature of pericarditis especially of infective etiology. Viral pericarditis can present with a prodrome of upper respiratory infection, while purulent pericarditis can present with acute onset of fever with chills and rigor. Tuberculous pericarditis can have low grade prolonged fever.Myalgia especially in viral pericarditis.Most of the patients will have difficulty in breathing secondary to chest pain during inspiration.
Signs
•Pericardial friction rub is pathognomonic of pericarditis. It is heard as a phasic scatching sound. It may vary with phases of respiration mostly increasing on inspiration. The pericardial rub is best audible in the lower left parasternal region. Classically pericardial rub has three components corresponding to ventricular systole, early ventricular diastole and atrial systole. Most often the pericardial rub is audible as a biphasic noise — a systolic and diastolic component. In 10 per cent of cases the pericardial rub is monophasic, during systolic phase only, when it can be confused with murmur. The pericardial rub most often waxes and wanes while this does not happen with murmur.
• Low grade to high grade fever can occur depending upon the etiology.
• Tachycardia is a feature of pericarditis.
•Patients are tachypnoeic and most often have shallow breathing secondary to painful restriction of inspiration.
Investigations
1)Blood Examination
Erythrocyte sedementaion rate (ESR) may be elevated in tuberculous; collagen and purulent pericarditis. The Dressler’s syndrome is associated with leukocytosis and elevated ESR.
2)Electrocardiogram (ECG)
Four stages of evolution of ECG changes may occur.
Stage 1: Acute changes. There is ST-segment elevation with concavity upwards and upright T-waves in all leads except aVR and V1. aVR may show ST-segment depression (Fig. 4.1) PR-segment depression could be seen especially in L2 and lateral chest leads (Fig. 4.2). The absence of reciprocal changes helps in distinguishing from acute myocardial infarction.
Stage 2: Several days later. Resolution of ST-segment and PR-segment to baseline. The T-wave flattens.
Stage 3: T-wave inversion.
Stage 4: T-wave normalizes – may take days to weeks.
3)Chest X-ray
In chest x-ray cardiac silhoutte will be normal unless associated with pericardial effusion in which case there will be cardiomegaly. Evidence of tuberculosis or malignancy in chest X-ray will help in etiological diagnosis.
4)Echocardiography
Pericarditis without effusion does not have any definite echocardiographic features. When the pericarditis lasts longer pericardial thickening may be recognized.
5)Computed Tomography (CT)
Magnetic resonance imaging (MRI) and transoesophageal echocardiography (TEE) have limited application.Differential Diagnosis Main symptom of pericarditis is chest pain and hence Acute Pericarditis must be differentiated from myocardial infarction, aortic dissection, pleuritis and pulmonary embolism. The classical features of pericardial pain will help in diagnosis: In ECG ST segment elevation does not occur in aortic dissection, pleuritis and pulmonary embolism. The ST-elevation of acute pericarditis has concavity upwards with upright T-waves and no reciprocal changes. These differentiate acute pericarditis from acute myocardial infarction
Table Echocardiography helps to differentiate these conditions from acute pericarditis.
Etiology
a) Idiopathic: Most common cause, though many of these cases could be of viral etiology.
b) Viral: The Coxsackie B and Echovirus are most common pathogens.
c) Purulent: Purulent pericarditis due to staphylococci, pneumococci or strephtococci can occur.
d) Tuberculous: Tuberculosis can infect the pericardium resulting in tuberculous pericarditis.
e) Pericarditis in acute myocardial infarction: Transmural myocardial infarction can cause pericardial inflammation in 12 – 15 per cent of cases. It is more often detected in anterior wall myocardial infarction and inferior wall with right ventricular infarction. With the widespread use of reperfusion therapy, the incidence of pericarditis in acute myocardial infarction has significantly come down.
f) Uremic: Uremic patients can develop pericarditis.
g) Neoplastic: Malignant tumours especially of lung and breast and lymphomas can involve the pericardium leading to pericarditis with effusion.
h) Collagen Disorders: Collagen disorders like lupus erythematosis, rheumatic fever and rheumatoid disease can cause pericardial inflammation.
i) Dressler’s Syndrome: Occurs 2 weeks to 2 years after acute myocardial infarction. The exact cause of Dressler’s syndrome is not clear, though proposed to be autoimmune in nature.
j) Post pericardiotomy Syndrome: Occurs 6 to 8 weeks after cardiac surgery. Thought to be autoimmune in mechanism.
k) Rare infecting organisms: Rarely fungal, rickettsial, spirochetal and parasitic infections can lead to pericarditis.
l) Traumatic: Traumatic perforation of the pericardium during procedures like pacemaker insertion, catheter ablation for arrhythmias or interventional procedures or pericardial perforation from penetrating chest injury or oesophageal perforation can cause pericardial
inflammation.
m) Radiation: Radiation to the chest can cause pericardial inflammation.
n)Other metabolic causes: Myxoedema and gout can also cause pericarditis.
Clinical PresentationSymptoms
Chest Pain
Chest pain is the most important symptom. It is retrosternal in location and patient usually locates the site of the pain without difficulty. The pain is severe and sharp and may radiate to the shoulder region and back. The pericardial pain increases on deep inspiration, coughing,swallowing and lying supine. Pain may be alleviated with patient sitting up and leaning forwards.
Fever
Fever is a feature of pericarditis especially of infective etiology. Viral pericarditis can present with a prodrome of upper respiratory infection, while purulent pericarditis can present with acute onset of fever with chills and rigor. Tuberculous pericarditis can have low grade prolonged fever.Myalgia especially in viral pericarditis.Most of the patients will have difficulty in breathing secondary to chest pain during inspiration.
Signs
•Pericardial friction rub is pathognomonic of pericarditis. It is heard as a phasic scatching sound. It may vary with phases of respiration mostly increasing on inspiration. The pericardial rub is best audible in the lower left parasternal region. Classically pericardial rub has three components corresponding to ventricular systole, early ventricular diastole and atrial systole. Most often the pericardial rub is audible as a biphasic noise — a systolic and diastolic component. In 10 per cent of cases the pericardial rub is monophasic, during systolic phase only, when it can be confused with murmur. The pericardial rub most often waxes and wanes while this does not happen with murmur.
• Low grade to high grade fever can occur depending upon the etiology.
• Tachycardia is a feature of pericarditis.
•Patients are tachypnoeic and most often have shallow breathing secondary to painful restriction of inspiration.
Investigations
1)Blood Examination
Erythrocyte sedementaion rate (ESR) may be elevated in tuberculous; collagen and purulent pericarditis. The Dressler’s syndrome is associated with leukocytosis and elevated ESR.
2)Electrocardiogram (ECG)
Four stages of evolution of ECG changes may occur.
Stage 1: Acute changes. There is ST-segment elevation with concavity upwards and upright T-waves in all leads except aVR and V1. aVR may show ST-segment depression (Fig. 4.1) PR-segment depression could be seen especially in L2 and lateral chest leads (Fig. 4.2). The absence of reciprocal changes helps in distinguishing from acute myocardial infarction.
Stage 2: Several days later. Resolution of ST-segment and PR-segment to baseline. The T-wave flattens.
Stage 3: T-wave inversion.
Stage 4: T-wave normalizes – may take days to weeks.
3)Chest X-ray
In chest x-ray cardiac silhoutte will be normal unless associated with pericardial effusion in which case there will be cardiomegaly. Evidence of tuberculosis or malignancy in chest X-ray will help in etiological diagnosis.
4)Echocardiography
Pericarditis without effusion does not have any definite echocardiographic features. When the pericarditis lasts longer pericardial thickening may be recognized.
5)Computed Tomography (CT)
Magnetic resonance imaging (MRI) and transoesophageal echocardiography (TEE) have limited application.Differential Diagnosis Main symptom of pericarditis is chest pain and hence Acute Pericarditis must be differentiated from myocardial infarction, aortic dissection, pleuritis and pulmonary embolism. The classical features of pericardial pain will help in diagnosis: In ECG ST segment elevation does not occur in aortic dissection, pleuritis and pulmonary embolism. The ST-elevation of acute pericarditis has concavity upwards with upright T-waves and no reciprocal changes. These differentiate acute pericarditis from acute myocardial infarction
Table Echocardiography helps to differentiate these conditions from acute pericarditis.
 |
| ECG Differentiation of Acutepericarditis and Acute Myocardial Infarction |
Treatment
Symptomatic Treatment
Pain relief can be achieved with indomethacin 25 to 50 mg. thrice daily; Ibuprofen 600 mg. thrice daily for 1 or 2 weeks. In case of persistence of pain prednisolone 40 to 60 mg. orally for 5 days and then tapered over 3 weeks is useful.
Specific Treatment
Specific treatment is directed to the etiology of pericarditis. Ideopathic and viral pericarditis do not require additional treatment.For tuberculous pericarditis, four drugs regime is recommended for 9 months, with atleast 6 months treatment after culture conversion. For pursulent pericarditis, appropriate antibiotic against the infecting organism should be given.
Follow Up
Most of the patients of ideopathic or viral pericarditis need follow up for atleast 1 month to make certain that the pericarditis process has completely resolved. Followup also is required to exclude the development of constrictive pericarditis especially in tuberculous and perulent pericarditis.
Complications
Recurrence ==> About 20 per cent cases of pericarditis especially idiopathic, viral or Dressler’s syndrome, can recur. If pericardial effusion occurs, then it needs management (see later).Recurrent pericarditis may require treatment with steroids.
Symptomatic Treatment
Pain relief can be achieved with indomethacin 25 to 50 mg. thrice daily; Ibuprofen 600 mg. thrice daily for 1 or 2 weeks. In case of persistence of pain prednisolone 40 to 60 mg. orally for 5 days and then tapered over 3 weeks is useful.
Specific Treatment
Specific treatment is directed to the etiology of pericarditis. Ideopathic and viral pericarditis do not require additional treatment.For tuberculous pericarditis, four drugs regime is recommended for 9 months, with atleast 6 months treatment after culture conversion. For pursulent pericarditis, appropriate antibiotic against the infecting organism should be given.
Follow Up
Most of the patients of ideopathic or viral pericarditis need follow up for atleast 1 month to make certain that the pericarditis process has completely resolved. Followup also is required to exclude the development of constrictive pericarditis especially in tuberculous and perulent pericarditis.
Complications
Recurrence ==> About 20 per cent cases of pericarditis especially idiopathic, viral or Dressler’s syndrome, can recur. If pericardial effusion occurs, then it needs management (see later).Recurrent pericarditis may require treatment with steroids.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.