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Pericarditis (Acute)

RCEM Learning: Acute Pericarditis NICE has not published any guidelines regarding pericarditis

Background Information

  • Idiopathic
  • Viral infection (e.g. Coxsackievirus)
  • Bacterial, fungal and parasitic infection
  • Autoimmune disorders (e.g. SLE, RA, sarcoidosis)
  • Metabolic causes (e.g. uraemia, myxoedema)
  • Post-myocardial infarction (Dressler syndrome)
 
Idiopathic and viral causes account for ~90% of cases of acute pericarditis 

  • Sudden onset chest pain
    • Retrosternal (but can be anywhere else)
    • Radiation to the trapezius ridge is highly specific for pericarditis
    • Pleuritic in nature
    • Relieved by sitting up and learning forward (worse lying flat)
  • Non-productive cough
 

  • Fever
  • Pericardial friction rub on auscultation
    • Best heard on expiration at lower left sternal edge
    • Audible when patient holds their breath (distinguishes from pleural rub)
  • Features of underlying cause

  • Young age
  • Absence of risk factors for coronary artery diseases
  • Preceding viral infection

Guidelines

Important investigations to be performed within the ED:
  • Bloods
    • ↑ WCCWhite cell count
    • ↑ CRPC-reactive protein
    • Troponin (↑ in 30-70% cases)
  • ECG
  • Imaging
    • Echocardiography – pericardial effusion or even tamponade
    • Chest X-ray – to exclude alternative causes of chest pain

Characteristic ECG findings:
  • Diffuse concave ST elevation
  • Global PR depression
  • Reciprocal changes in aVR and V1 (ST depression and PR elevation)

For a work-up of chest pain. Troponin, ECG, Chest X-ray is always done.


Diagnosis of acute pericarditis should be made when at least 2 out of 4 of the following are present:
  • Characteristic chest pain
  • Pericardial friction rub
  • Suggestive ECG changes
  • New or worsening pericardial effusion (on echo)

If ANY of the following high-risk features are present → admit for inpatient management
  • Fever (>38 C)
  • Subacute course
  • Large pericardial effusion (>20mm)
  • Cardiac tamponade
  • Failure to respond to aspirin / NSAIDs
  • ↑ Troponin (indicative of myopericarditis)
  • Immunosuppression
  • Oral anticoagulant therapy
  • Trauma
 

  • Activity restriction
    • Avoid strenuous physical activity until asymptomatic and biomarkers have normalised
    • Advise athletes to not compete in competitive sports for at least 3 months post-resolution
  • 1st line:  NSAIDs+ colchicine  
    • Stop NSAIDs after symptom resolution
    • Continue colchicine for another 3 months after symptom resolution 
Steroids should only be considered if the underlying cause is immune mediated or in uraemic pericarditis.

References

Author: Adams Lau  
Editor:
Reviewer: