Acute Pericarditis

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Contents

Major clinical manifestations:

  • Chest pain
  • Pericardial friction rub
  • Widespread ST Elevation or PR depression
  • Pericardial effusion
  • 2 out of 4 necessary to make diagnosis
  • Myopericarditis: depressed LV function, elevated biomarkers

Biomarkers

  • Troponin elevated in 32-49% of patients with acute idiopathic pericarditis
  • Features associated with + Tn:
  • Younger age
  • Male
  • Pericardial effusion
  • Recent infection
  • ST segment elevations

Evolution of EKG changes

  1. Acute phase: ST elevations and PR depression
  2. Normalization of ST and PR segments
  3. Diffuse T wave inversions
  4. T wave inversions may persist or normalize

EKG Changes

  • ST elevation begins at J-point
  • Rarely greater than 5 mm
  • Usually remains concave
  • ST depression absent
  • ST elevation and T wave inversion don’t occur together
  • PR depression due to atrial current of injury
  • No hyperacute T waves or Q waves

Diagnostic Workup

  • ECG
  • CXR
  • PPD
  • ANA if appropriate
  • HIV
  • Blood cultures if febrile

Echo

  • All patients with suspected pericardial disease
  • ACC/AHA/ASE Class I recommendation
  • Finding of an effusion is helpful in making the diagnosis
  • Absence of effusion does not rule out dx
  • Helpful in diagnosis of purulent pericarditis, myocarditis or ruling out MI

Hospital Admission

  • Subacute symptoms
  • High fever (>38ºC) and leukocytosis
  • Evidence suggesting tamponade
  • Large pericardial effusion (> 20 mm)
  • Immunosuppressed state
  • Coumadin
  • Acute trauma
  • Failure to respond to NSAIDs in 7 days

Treatment

  • ASA or NSAIDS
  • ESC recommends ibuprofen
  • Ibuprofen: 400-800mg Q6-8 hrs
  • Aspirin: 800mg Q6-8 hrs
  • May need to treat as long as 3-4 weeks

Colchicine

  • COPE trial[1]
  • Open-label randomized trial:
  • 120 pts with 1st episode acute pericarditis
  • ASA or ASA plus Colchicine for 3-4 weeks
  • Colchicine dosing: 2mg x 1, then 0.5mg BID
  • Colchicine group:
  • Significantly lower recurrence rate (10.7% v 32.3%) and rate of persistent sx at 72 hrs (11.7% v 36.7%)

Steroids

  • Should only be considered if sx refractory to NSAIDS or colchicine
  • Associated with recurrence of symptoms
  • 2004 ESC guidelines:
  • Acute pericarditis due to connective tissue disease
  • Autoreactive (immune-mediated) pericarditis
  • Uremic pericarditis

References

  1. Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COPE trial. Circulation. 2005; 112: 2012–2016
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