Clinical Presentation and Diagnostic Evaluation of Acute Pericarditis

8/7/2015 Clinicalpresentationanddiagnosticevaluationofacutepericarditis

http://www.uptodate.com/contents/clinicalpresentationanddiagnosticevaluationofacutepericarditis?topicKey=CARD%2F4940&elapsedTimeMs=7&v 1/26

OfficialreprintfromUpToDate www.uptodate.com2015UpToDate

AuthorMassimoImazio,MD,FESC

SectionEditorMartinMLeWinter,MD

DeputyEditorBrianCDowney,MD,FACC

Clinicalpresentationanddiagnosticevaluationofacutepericarditis

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Jun2015.|Thistopiclastupdated:Oct31,2014.

INTRODUCTIONThepericardiumisafibroelasticsacmadeupofvisceralandparietallayersseparatedbya(potential)space,thepericardialcavity.Inhealthyindividuals,thepericardialcavitycontains15to50mLofanultrafiltrateofplasma.Pericardialdiseasesarerelativelycommoninclinicalpracticeandmayhavedifferentpresentationseitherasisolateddiseaseorasamanifestationofasystemicdisorder.Althoughtheetiologyisvariedandcomplex,thepericardiumhasarelativelynonspecificresponsetothesedifferentcauseswithinflammationofthepericardiallayersandpossibleincreasedproductionofpericardialfluid.Chronicinflammationwithfibrosisandcalcificationcanleadtoarigid,usuallythickenedandcalcifiedpericardium,withpossibleprogressiontopericardialconstriction.

Diseasesofthepericardiumpresentclinicallyinoneofseveralways[1]:

Acutepericarditisreferstoinflammationofthepericardialsac.Thetermmyopericarditis,orperimyocarditis,isusedforcasesofacutepericarditisthatalsodemonstratemyocardialinflammation.Theclinicalpresentationanddiagnosticevaluationforacutepericarditiswillbereviewedhere.Theetiologyofpericarditis,treatmentandprognosisofacutepericarditis,andotherpericardialdiseaseprocessesarediscussedseparately.(See"Etiologyofpericardialdisease"and"Treatmentofacutepericarditis"and"Recurrentpericarditis"and"Myopericarditis"and"Cardiactamponade"and"Constrictivepericarditis"and"Diagnosisandtreatmentofpericardialeffusion".)

EPIDEMIOLOGYAcutepericarditisisthemostcommondisorderinvolvingthepericardium.Epidemiologicstudiesarelacking,andtheexactincidenceandprevalenceofacutepericarditisareunknown.However,acutepericarditisisrecordedinabout0.1to0.2percentofhospitalizedpatientsand5percentofpatientsadmittedtotheEmergencyDepartmentfornonischemicchestpain[2,3].

Acutepericarditisisacommondisorderinseveralclinicalsettings,whereitmaybethefirstmanifestationofanunderlyingsystemicdiseaseormayrepresentanisolatedprocess(table1).Indevelopedcountries,mostcasesofacutepericarditisareconsideredofpossibleorconfirmedviralorigin,althoughtheexactetiologyofmostcasesremainsundeterminedfollowingatraditionaldiagnosticapproach[57].

Priortothewidespreadavailabilityofantiretroviraltherapytotreatinfectionwiththehumanimmunodeficiencyvirus(HIV),pericardialdiseasewasthemostfrequentcardiovascularmanifestationoftheacquiredimmunedeficiencysyndrome(AIDS)[8,9].However,indevelopedcountrieswithaccesstoHIVtherapy,patientswithHIVinfectionwhodevelopacutepericarditishaveanetiologicspectrumverysimilartononHIVinfectedpatients.Onthecontrary,HIVinfectionandtuberculosispersistasmajorcausesofacutepericarditisin

AcuteandrecurrentpericarditisPericardialeffusionwithoutmajorhemodynamiccompromiseCardiactamponadeConstrictivepericarditisEffusiveconstrictivepericarditis

InanobservationalstudyfromanurbanareainNorthernItalytheincidenceofacutepericarditiswas27.7casesper100,000personsperyear[4].

InanobservationalstudyfromFinlandthatincluded670,409cardiovascularadmissionsto29hospitalsacrossthecountryovera9.5yearperiod,thestandardizedincidencerateforpericarditisrequiringhospitalizationwas3.3casesper100,000personyears[3].



developingcountries.(See"CardiacandvasculardiseaseinHIVinfectedpatients",sectionon'Pericardialdisease'.)

CLINICALFEATURESAcutepericarditiscanpresentinavarietyofways,dependingontheunderlyingetiology.Patientswithaninfectiousetiologymaypresentwithsignsandsymptomsofsystemicinfectionsuchasfeverandleukocytosis.Viraletiologiesinparticularmaybeprecededbyflulikerespiratoryorgastrointestinalsymptoms.Patientswithaknownautoimmunedisorderormalignancymaypresentwithsignsorsymptomsspecifictotheirunderlyingdisorder.

Themajorclinicalmanifestationsofacutepericarditisinclude[5]:

ChestpainThevastmajorityofpatientswithacutepericarditispresentwithchestpain(>95%ofcases)[10].Chestpainislikelytobepresentincasesofacutepericarditiscausedbyinfection,butmaybeminimalorabsentinpatientswithuremicpericarditisorpericarditisassociatedwitharheumatologicdisorder(althoughinsomepatientspleuriticchestpainandpericarditisistheinitialpresentationofsystemiclupuserythematosus).

Chestpainthatresultsfromacutepericarditisistypicallyfairlysuddeninonsetandoccursovertheanteriorchest.Unlikepainfrommyocardialischemia,chestpainduetopericarditisismostoftensharpandpleuriticinnature,withexacerbationbyinspirationorcoughing.Oneofthemostdistinctivefeaturesisthetendencyforadecreaseinintensitywhenthepatientsitsupandleansforward[5,11].Thisposition(seated,leaningforward)tendstoreducepressureontheparietalpericardium,particularlywithinspiration,andmayalsoallowforsplintingofthediaphragm[12].

However,dull,oppressivepainorradiationofthepaintotheshoulders(particularlythetrapeziusridges)mayoccurinsuchcasesitisdifficulttodistinguishpericarditisfromothercausesofchestpain[5,11].Thechestpainofpericarditismustalwaysbedistinguishedfromothercommonand/orlifethreateningcausesofchestpainsuchasmyocardialischemia,pulmonaryembolism,aorticdissection,gastroesophagealrefluxdisease,andmusculoskeletalpain.(See"Differentialdiagnosisofchestpaininadults".)

PericardialfrictionrubThepresenceofapericardialfrictionrubonphysicalexaminationishighlyspecificforacutepericarditis(movie1).Pericardialfrictionrubs,whichoccurduringthemaximalmovementoftheheartwithinitspericardialsac,aresaidtobegeneratedbyfrictionbetweenthetwoinflamedlayersofthepericardium.However,thiscommonlyofferedexplanationforitsmechanismmaybeanoversimplificationaspatientswithapericardialeffusionmayalsohaveanaudiblefrictionrub.

Theclassicfrictionrubconsistsofthreephases,correspondingtomovementoftheheartduringatrialsystole(whichisnotheardinpatientswithatrialfibrillation),ventricularsystole,andtherapidfillingphaseofearlyventriculardiastole.However,somerubsarepresentonlyduringone(onecomponent)ortwophases(twocomponents)ofthecardiaccycle[13].Inareviewofauscultationandphonocardiographyin100patientswithapericardialrub,therubwastriphasicin56percentofpatientsinsinusrhythmoverall,biphasicrubswerepresentin33percentandmonophasicrubsin15percent[13].

Pericardialrubshaveasuperficialscratchyorsqueakingqualitythatisbestheardwiththediaphragmofthestethoscope.Theymaybelocalizedorwidespread,butareusuallyloudestovertheleftsternalborder[13].Theintensityoftherubfrequentlyincreasesafterapplicationoffirmpressurewiththediaphragm,duringsuspendedrespiration,andwiththepatientleaningforwardorrestingonelbowsandknees(picture1).Thislastmaneuverisdesignedtoincreasecontactbetweenvisceralandparietalpericardium,butisseldomusedinpracticesinceitiscumbersomeforthepatient.

Frictionrubstendtovaryinintensityandcancomeandgooveraperiodofhourstherefore,thesensitivityfordetectionofarubisvariableanddependsinlargepartonthefrequencyofauscultation[11].Pericardialrubsmaybeeasiertohearinpatientswithoutapericardialeffusion,butthisfindingisnotuniversalandisnotwell

Chestpaintypicallysharpandpleuritic,improvedbysittingupandleaningforwardPericardialfrictionrubasuperficialscratchyorsqueakingsoundbestheardwiththediaphragmofthestethoscopeovertheleftsternalborder

Electrocardiogram(ECG)changesnewwidespreadSTelevationorPRdepressionPericardialeffusion



documented.Inareportof100patientswithacutepericarditis,apericardialrubwaspresentin34of40(85percent)withoutaneffusion[14].Thisprevalenceisconsiderablyhigherthanthe35percentincidenceoffrictionrubsreportedinanotherseries[10].

Suspensionofrespirationduringauscultationpermitsdistinctionofapericardialfrictionrubfromapleuropericardialorpleuralrub.Apleuropericardialrubresultsfromthefrictionbetweentheinflamedpleuraandtheparietalpericardium,whileapleuralrubistheresultoffrictionbetweentheinflamedvisceralandparietalpleura.Assuch,pleuropericardialandpleuralrubscanbeheardonlyduringtheinspiratoryphaseofrespiration.(See"Auscultationofheartsounds",sectionon'Pericardialfrictionrubandotheradventitioussounds'.)

ElectrocardiogramChangesintheelectrocardiogram(ECG)inpatientswithacutepericarditissignifyinflammationoftheepicardium,sincetheparietalpericardiumitselfiselectricallyinert.However,somecausesofpericarditisdonotresultinsignificantinflammationoftheepicardiumand,assuch,maynotaltertheECG.Anillustrationofthisisuremicpericarditis,inwhichthereisprominentfibrindepositionbutlittleornoepicardialinflammation.Asaresult,theECGoftenshowsnoneofthechangesassociatedwithpericarditis[15].(See"Pericarditisinrenalfailure".)

Theelectrocardiogram(ECG)inacutepericarditiscanevolvethroughasmanyasfourstagesofchanges[5,11].However,pericarditisdoesnotalwaysresultinsignificantECGchanges.Oneseriesof300consecutivepatientswithacutepericarditisnotedtypicalECGevolutionin60percentofcases[10].

ThetypicalprogressionofECGchangesinpatientswithacutepericarditisisdescribedbelow:

ThetemporalevolutionofECGchangeswithacutepericarditisishighlyvariablefromonepatienttoanother[16].TreatmentcanaccelerateoralterECGprogression.ThedurationoftheECGchangesinpericarditisalsodependsuponitscauseandtheextentoftheassociatedmyocardialdamage[17].

AtypicalECGchangesareseeninupto40percentofpatientswithacutepericarditis[10].Forexample,localizedSTelevationandTwaveinversionoccurbeforeSTsegmentnormalizationinaminorityofpatientswithacutepericarditiswithoutmyocardialinvolvement.ThesechangescansimulateECGchangesseeninpatientswithanacutecoronarysyndrome.(See'ECGdifferentiationfromacutemyocardialinfarction'belowand"ECGtutorial:Myocardialischemiaandinfarction"and"ECGtutorial:STandTwavechanges".)

Sustainedarrhythmiasareuncommoninacutepericarditis,exceptinthepostthoracotomysetting.Thiswasillustratedinareviewof100consecutivepatientsinwhichonlysevenarrhythmiaswereidentifiedallwereatrialandalloccurredinpatientswithunderlyingheartdisease[18].Inaseparatereportcomparingpatientswithmyopericarditisandsimpleacutepericarditis,cardiacarrhythmiaswerealsomorecommonlypresentinpatientswithmyopericarditis(oddsratio17.6,95%confidenceinterval5.7to54.1)[4].Thus,thepresenceofatrialorventriculararrhythmiasissuggestiveofconcomitantmyocarditisoranunrelatedcardiacdisease.

ECGdifferentiationfromacutemyocardialinfarctionWhilebothacutepericarditisandacute

Stage1,seeninthefirsthourstodays,ischaracterizedbydiffuseSTelevation(typicallyconcaveup)withreciprocalSTdepressioninleadsaVRandV1(waveform1).Thereisalsoanatrialcurrentofinjury,reflectedbyelevationofthePRsegmentinleadaVRanddepressionofthePRsegmentinotherlimbleadsandintheleftchestleads,primarilyV5andV6.Thus,thePRandSTsegmentstypicallychangeinoppositedirections.PRsegmentdeviation,whichishighlyspecificthoughlesssensitive,isfrequentlyoverlooked.

TheTPsegmentisrecommendedasthebaselineforcomparisonwhenmeasuringbothPRandSTsegmentchangesinacutepericarditis[16].

Stage2,typicallyseeninthefirstweek,ischaracterizedbynormalizationoftheSTandPRsegments.

Stage3ischaracterizedbythedevelopmentofdiffuseTwaveinversions,generallyaftertheSTsegmentshavebecomeisoelectric.However,thisstageisnotseeninsomepatients.

Stage4isrepresentedbynormalizationoftheECGorindefinitepersistenceofTwaveinversions("chronic"pericarditis).



myocardialinfarctioncanpresentwithchestpainandelevationsincardiacbiomarkers,theelectrocardiographicchangesinacutepericarditisdifferfromthoseinacuteSTelevationMI(STEMI)inseveralways[19].ThesedistinctionsassumethatthepericarditisdoesnotoccurduringorsoonafteranacuteMI.(See"Electrocardiograminthediagnosisofmyocardialischemiaandinfarction"and"Pericardialcomplicationsofmyocardialinfarction"and"ECGtutorial:STandTwavechanges"and"ECGtutorial:Myocardialischemiaandinfarction".)

ECGdifferentiationfromearlyrepolarizationTheearlyrepolarizationvariantseenonanECGmaybepresentinasmanyas30percentofyoungadultsandisoftenconfusedwithacutepericarditis[20].EarlyrepolarizationischaracterizedbySTelevationoftheJpoint,whichrepresentsthejunctionbetweentheendoftheQRScomplex(terminationofdepolarization)andthebeginningoftheSTsegment(onsetofventricularrepolarization).Asaresult,thereiselevationoftheSTsegmentitself,whichmaintainsitsnormalconfiguration(waveform4).Inearlyrepolarization,STelevationismostoftenpresentintheanteriorandlateralchestleads(V3V6),althoughotherleadscanbeinvolved.(See"ECGtutorial:Miscellaneousdiagnoses",sectionon'Earlyrepolarization'.)

MorphologyTheSTsegmentelevationinacutepericarditisbeginsattheJpoint,whichrepresentsthejunctionbetweentheendoftheQRScomplex(terminationofdepolarization)andthebeginningoftheSTsegment(onsetofventricularrepolarization).TheSTsegmentelevationrarelyexceeds5mm,andusuallyretainsitsnormalconcavity(waveform1).Insomecasesofacutepericarditis,theSTsegmentrisesobliquelyinastraightline.AlthoughsimilarpatternscanoccurwithSTEMI,thetypicalfindinginaSTEMIpatientisconvex(domeshaped)STelevation(apatternnotcharacteristicofacutepericarditis)thatmaybemorethan5mminheight(waveform2).Thebasisforthesemorphologicdifferencesisnotknown,butisprobablyrelatedtothegreaterinjurycurrentassociatedwithinfarction.

DistributionSTsegmentelevationsinSTEMIarecharacteristicallylimitedtoanatomicalgroupingsofleadsthatcorrespondtothelocalizedvascularareaoftheinfarct(anteroseptalandanteriorleadsV1toV4lateralleadsI,aVL,V5,V6inferiorleadsII,III,aVF)(waveform2).Thepericardiumenvelopstheheart,thereforetheSTchangesaremoregeneralizedandtypicallyarepresentinmostleads(waveform1).Inpericarditis,STsegmentelevationintheprecordialleadsismostcommonlyseeninV5andV6,andindecreasingfrequencyfromV4toV1,whileinthelimbleads,itisoftenmoreevidentinleadsIandIIthaninleadsIII,aVF,andaVL[17].

ReciprocalchangesAcuteSTEMIisoftenassociatedwithreciprocalSTsegmentchanges,whicharenotseenwithpericarditisexceptinleadsaVRandV1.

ConcurrentSTandTwavechangesSTsegmentelevationandTwaveinversionsdonotgenerallyoccursimultaneouslyinpericarditis,whiletheycommonlycoexistinacuteSTEMI(waveform2).Furthermore,theevolutionofrepolarizationabnormalitiesoftentakesplacemoreslowlyandmoreasynchronouslyamongaffectedleadsinpericarditisthaninSTEMI.

HyperacuteTwavesPeakedTwaves(>10mmhighinprecordialleads,>5mmhighinlimbleads),alsoreferredtoashyperacuteTwaves,canbeseeninSTEMIbutarenottypicalofpericarditis(waveform3AB).Rarely,fusionoftheSTsegmentandTwaveintoasinglemonophasicwaveinpericarditiscanmimictheappearanceofhyperacuteTwaves.

QwavesPathologicQwaves,whichmayoccurwithextensiveinjuryinSTEMI,aregenerallynotseeninpericarditis.TheabnormalQwavesinMIreflectthelossofpositivedepolarizationvoltagesbecauseoftransmuralmyocardialnecrosis.Pericarditis,ontheotherhand,generallycausesonlysuperficialinflammation.AbnormalQwavesarenotseenunlessthereisconcomitantmyocarditisorpreexistingcardiomyopathyormyocardialinfarction.

PRsegmentPRelevationinaVRwithPRdepressioninotherleadsduetoaconcomitantatrialcurrentofinjuryisfrequentlyseeninacutepericarditisbutrarelyseeninacuteSTEMI.

QTprolongationProlongationoftheQTintervalwithregionalTwaveinversion(intheabsenceofdrugeffectsorrelevantmetabolicdisorders)favorsthediagnosisofmyocardialischemia(ormyopericarditis)overpericarditisalone.



Thefollowingelectrocardiographicfeaturescanbehelpfulindistinguishingacutepericarditisfromearlyrepolarization:

Laboratoryandimagingfindings

EchocardiogramEchocardiographyisoftennormalinpatientswiththeclinicalsyndromeofacutepericarditisunlessthereisanassociatedpericardialeffusion.Whilethefindingofapericardialeffusioninapatientwithknownorsuspectedpericarditissupportsthediagnosis,theabsenceofapericardialeffusionorotherechocardiographicabnormalitiesdoesnotexcludeit.Inoneseriesof300consecutivepatientswithacutepericarditis,pericardialeffusionwaspresentin180patients(60percent).Inmostcasestheeffusionwassmallormoderateinsize(79and10percent,respectively)withouthemodynamicconsequences.Cardiactamponadewaspresentinonly5percentofpatients[10].(See"Echocardiographicevaluationofthepericardium"and"Diagnosisandtreatmentofpericardialeffusion".)

ChestxrayChestradiographyistypicallynormalinpatientswithacutepericarditis.Althoughpatientswithasubstantialpericardialeffusionmayexhibitanenlargedcardiacsilhouettewithclearlungfields(image1),thisfindingisuncommoninacutepericarditissinceatleast200mLofpericardialfluidmustaccumulatebeforethecardiacsilhouetteenlarges[2,5].However,acutepericarditisshouldbeconsideredintheevaluationofapatientwithnewandotherwiseunexplainedcardiomegaly.

CardiacbiomarkersAcutepericarditismaybeassociatedwithincreasesinserumbiomarkersofmyocardialinjurysuchascardiactroponinIorT.Inoneseriesof118consecutivecaseswithidiopathicacutepericarditisanelevatedlevelofcardiactroponinIwasdetectedin38patients(32percent)[23].Suchpatientsshouldbeconsideredtohavemyopericarditis.(See'Myopericarditis'belowand"Myopericarditis",sectionon'Laboratorystudies'.)

SignsofinflammationSincepericarditisisaninflammatorydisease,laboratorysignsofinflammationarecommoninpatientswithacutepericarditis.Theseincludeelevationsinthewhitebloodcellcount,erythrocytesedimentationrate,andserumCreactiveproteinconcentration.Whileelevationinthesemarkerssupportsthediagnosis,theyareneithersensitivenorspecificforacutepericarditis.Additionally,inthehyperacutephaseofpericarditis,thesemarkersmayremainnormalandincreasedlevelsmaybefoundonlyonfollowup.

DIAGNOSISThediagnosisofacutepericarditisisusuallysuspectedbasedonahistoryofcharacteristicpleuriticchestpain,andconfirmedifapericardialfrictionrubispresent.Pericarditisshouldalsobesuspectedinapatientwithpersistentfeverandpericardialeffusionornewunexplainedcardiomegaly.Additionaltesting,whichtypicallyincludesbloodwork,chestradiography,electrocardiography,andechocardiography,cansupportthediagnosisbutisfrequentlynormalorunrevealing.Theelectrocardiogramisusuallythemosthelpfultestintheevaluationofpatientswithsuspectedacutepericarditis.Echocardiographyisoftennormal,butcanbeanessentialpartoftheevaluationifthereisevidenceofanassociatedpericardialeffusionand/orsignsofcardiactamponade.

EvaluationForapatientwhopresentswithsuspectedacutepericarditis,itisourpracticetoperformthefollowingstudies:

STelevationsoccurinboththelimbandprecordialleadsinmostcasesofacutepericarditis(47of48inonestudy),whereasaboutonehalfofsubjectswithearlyrepolarizationhavenoSTdeviationsinthelimbleads[21].

PRdeviationandevolutionoftheSTandTchangesstronglyfavorpericarditis,asneitherisseeninearlyrepolarization.

IftheratioofSTelevationtoTwaveamplitudeinleadV6exceeds0.24,acutepericarditisispresent(positiveandnegativepredictivevaluesareboth100percent)[22].

InitialhistoryandphysicalexaminationThisevaluationshouldconsiderdisordersthatareknowntoinvolvethepericardium,suchaspriormalignancy,autoimmunedisorders,uremia,recentmyocardialinfarction,andpriorcardiacsurgery.Theexaminationshouldpayparticularattentiontoauscultationforapericardialfrictionrubandthesignsassociatedwithtamponade.(See"Etiologyofpericardialdisease"



and"Pericardialdiseaseassociatedwithmalignancy"and"Noncoronarycardiacmanifestationsofsystemiclupuserythematosusinadults",sectionon'Pericardialdisease'and"Pericarditisinrenalfailure"and"Pericardialcomplicationsofmyocardialinfarction"and"Cardiactamponade".)

Initialtestingshouldinclude:

Anelectrocardiograminallcases.(See'Electrocardiogram'above.)

Chestradiographyinallcases.(See'Chestxray'above.)

Completebloodcount,troponinlevel,erythrocytesedimentationrate,andserumCreactiveproteinlevel.(See'Cardiacbiomarkers'above.)

Bloodculturesiffeverhigherthan38C(100.4F)orsignsofsepsis.

Echocardiographyshouldbeperformedinallcases,withurgentechocardiographyifcardiactamponadeissuspected.Evenasmalleffusioncanbehelpfulinconfirmingthediagnosisofpericarditis,althoughtheabsenceofaneffusiondoesnotexcludethediagnosis[24].Inaddition,echocardiographycanbeparticularlyhelpfulifpurulentpericarditisissuspected,ifthereisconcernaboutmyocarditis,orifthereisradiographicevidenceofcardiomegaly,particularlyifthisisanewfinding.(See'Echocardiogram'aboveand"Echocardiographicevaluationofthepericardium".)

The2003AmericanCollegeofCardiology/AmericanHeartAssociation/AmericanSocietyofEchocardiography(ACC/AHA/ASE)guidelinesfortheclinicalapplicationofechocardiographystatedthatevidenceand/orgeneralagreementsupportedtheuseofechocardiographyfortheevaluationofallpatientswithsuspectedpericardialdisease[25].Similarly,a2013expertconsensusstatementfromtheASErecommendsechocardiographyforallpatientswithacutepericarditis[24].

Additionaltestingmayinclude:

Tuberculinskintestoraninterferongammareleaseassay(eg,QuantiFERONTBassay)ifnotrecentlyperformed.TheinterferongammareleaseassayismosthelpfulinimmunocompromisedorHIVpositivepatientsandinregionswheretuberculosisisendemic.(See"DiagnosisofpulmonarytuberculosisinHIVnegativepatients"and"Tuberculouspericarditis".)

Antinuclearantibody(ANA)titerinselectedcases(eg,youngwomen,especiallythoseinwhomthehistorysuggestsarheumatologicdisorder).Rarely,acutepericarditisistheinitialpresentationofsystemiclupuserythematosus(SLE).ItisimportanttorecognizethatapositiveANAisanonspecifictest.ArheumatologyconsultshouldbesoughtinpatientswithpericarditisinwhomadiagnosisofSLEisbeingentertained.

HIVserology(see"CardiacandvasculardiseaseinHIVinfectedpatients",sectionon'Pericardialdisease')

Computedtomography(CT)maybeusefultoconfirmthediagnosisandespeciallyevaluateconcomitantpleuropulmonarydiseasesandlymphadenopathies,thussuggestingapossibleetiologyofpericarditis(ie,TB,lungcancer)[24].Noncalcifiedpericardialthickeningwithpericardialeffusionissuggestiveofacutepericarditis.Moreover,withtheadministrationofiodinatedcontrastmedia,enhancementofthethickenedvisceralandparietalsurfacesofthepericardialsacconfirmsthepresenceofactiveinflammation.Computedtomographicattenuationvaluescanhelpinthedifferentiationofexudativefluid(20to60Hounsfieldunits),asfoundwithpurulentpericarditis,andsimpletransudativefluid(



ClinicaldiagnosticcriteriaAcutepericarditisreferstoinflammationofthepericardialsac.Thetermmyopericarditis,orperimyocarditis,isusedforcasesofacutepericarditisthatalsodemonstratefeaturesconsistentwithmyocardialinflammation.

Becausethesamevirusesthatareresponsibleforacutepericarditiscanalsocausemyocarditis,itisnotuncommontofindsomedegreeofmyocardialinvolvementinpatientswithacutepericarditis.Theterms"myopericarditis"and"perimyocarditis"aresometimesusedinterchangeablyortheycanbeusedtoindicatethedominantsiteofinvolvement.Casesthatinvolvethemyocardiuminwhichpericarditisispredominantarereportedasmyopericarditisalternatively,thetermperimyocarditisissometimesusedwhenmyocardialinvolvementismostprominent.However,inclinicalpractice,myopericarditisismorecommonandthistermisoftenusedinbothsenses.(See"Myopericarditis".)

AcutepericarditisAcutepericarditisisdiagnosedbythepresenceofatleasttwoofthefollowingcriteria(table2)[5,11,14,26,27]:

Whileechocardiographyisoftennormal,andtheabsenceofapericardialeffusiondoesnotexcludepericarditis,theechocardiogramremainsanessentialpartoftheevaluationifthereisevidenceofanassociatedpericardialeffusionand/orsignsofcardiactamponade.

MyopericarditisWhenacutepericarditisispresent,myopericarditiscanbediagnosedbythedetectionofoneorbothofthefollowingintheabsenceofevidenceofanothercause[2831]:

Amorecompletediscussionofthediagnosisofmyopericarditisispresentedseparately.(See"Myopericarditis",sectionon'Diagnosis'.)

IDENTIFYINGTHEETIOLOGYTheyieldofthestandarddiagnosticevaluationtodeterminetheetiologyofacutepericarditisisrelativelylow.Thiswasillustratedinthreeseriesthatincludedatotalof784unselectedpatientswhounderwentanextensiveevaluation[14,26,32].Aspecificdiagnosiswasestablishedinonly130patients(17percent)(table3).Themostcommonlyconfirmeddiagnoseswere:

InWesterncountries,unlessthereisanapparentmedicalorsurgicalconditionknowntobeassociatedwithpericarditis,mostcasesofacutepericarditisinimmunocompetentpatientsareduetoviralinfectionorareidiopathic(table1andtable3)[6,10,27,3235].Acuteviraloridiopathicpericarditistypicallyfollowsabriefandbenigncourseafterempirictreatmentwithantiinflammatorydrugs.(See"Treatmentofacutepericarditis".)

Wedonotroutinelyobtainviralstudies,sincetheyieldislowandmanagementisnotaltered[26].

Pericardiocentesisshouldbeperformedfortherapeuticpurposesinpatientswithcardiactamponade.(See'Pericardiocentesis'belowand"Treatmentofacutepericarditis",sectionon'Interventionaltherapeutictechniques'.)

Pericardiocentesisshouldbeconsideredfordiagnosticpurposesinpatientssuspectedofhavingamalignantorbacterialetiology,orinpatientswithaneffusionrefractorytomedicaltherapy.(See'Pericardiocentesis'below.)

Typicalchestpain(sharpandpleuritic,improvedbysittingupandleaningforward)Pericardialfrictionrub(asuperficialscratchyorsqueakingsoundbestheardwiththediaphragmofthestethoscopeovertheleftsternalborder)(movie1)

Suggestivechangesontheelectrocardiogram(typicallywidespreadSTsegmentelevation)(waveform1)Neworworseningpericardialeffusion

Elevationinserumcardiacbiomarkers,suchascardiactroponinIorTNeworpresumednewfocalorgloballeftventricularsystolicdysfunctiononimagingstudies

Neoplasia5percentTuberculosis4percentAutoimmuneetiologies5percentPurulentpericarditis1percent



Becauseoftherelativelybenigncourseassociatedwiththecommoncausesofpericarditis,itisnotnecessarytosearchfortheetiologyinallpatientswithacutepericarditis.Initialeffortsshouldfocusuponexcludingasignificanteffusionortamponadeandtheidentificationofpatientsinwhomamorecomprehensiveevaluationshouldbeperformedtoexcludecausesthatrequirespecifictherapy(eg,malignancy,tuberculosisorpurulentpericarditis)(table1)[10].Inaddition,amongpatientsathighriskofcoronarydisease,myocardialischemiamustberuledoutbyappropriatestudies.

IndicationsforpericardiocentesisandpericardialbiopsyStudiesinpatientswithacutepericarditishavereportedalowyieldfordiagnosticpericardiocentesisandpericardialbiopsyhowever,someauthorshaveadvocatedforamoreextensiveuseofthesetechniquesfordiagnosticpurposes.Themajorityofpatientswithuncomplicatedacutepericarditisdonotrequireinvasivepericardialprocedures.However,somehighriskpatientsmayrequirepericardiocentesisforboththerapeuticanddiagnosticpurposes(table4).Inaddition,whilepericardialbiopsyisnotrequiredtomakethediagnosisofacutepericarditis,itmayrarelybenecessaryinanattempttodiagnoseaspecificetiology.(See"Treatmentofacutepericarditis",sectionon'Interventionaltherapeutictechniques'.)

PericardiocentesisInpatientswithapericardialeffusion,pericardiocentesisorsurgicaldrainagecanservebothdiagnosticandtherapeuticpurposes.Amongpatientswithacutepericarditis,decisionsregardingdrainageofthepericardialspacearebaseduponthepresenceofanassociatedeffusion,itsechocardiographiccharacteristics(eg,sizeandcomposition),andclinicalsignificance(eg,causinghemodynamiccompromise).

Adetaileddiscussionregardingtheperformanceofpericardiocentesisandthetreatmentofpericardialeffusionsispresentedseparately.(See"Diagnosisandtreatmentofpericardialeffusion".)

PericardialbiopsyPericardialbiopsyisgenerallyperformedasapartofatherapeuticprocedure(surgicaldrainage)inpatientswithrecurrentpericardialeffusionsandcardiactamponadeafterpriorpericardiocentesis(therapeuticbiopsy),andasadiagnosticprocedureinpatientswithanillnesslastingmorethanthreeweeksdespitetreatmentwithoutadefinitediagnosis.Technicaladvancesininstrumentationwithintroductionofpericardioscopy,andincontemporaryvirologyandmolecularbiologyhaveimprovedthediagnosticvalueofepicardial/pericardialbiopsy.Thediagnosticyieldofpericardialbiopsyistypicallyhigherinpatientswithpericardialeffusionwithorwithoutpericarditisthaninthosewhopresentwithapparentacutepericarditiswithouteffusion.Polymerasechainreactiontechniquesmayrepresentausefuladjuncttoconventionallaboratorystudiesintheinvestigationofpericardialsamples,allowingtherapididentificationofmicroorganismsotherwisenoteasilyfound[36,37].Tissuesamplesshouldbesentforcytology,tumormarkers,gramstain,bacterialcultures,and,iftuberculosisissuspected,polymerasechainreactiontesting.(See"Diagnosisandtreatmentofpericardialeffusion",sectionon'Pericardialfluidanalysisandbiopsy'.)

DETERMINATIONOFRISKANDNEEDFORHOSPITALIZATIONManycliniciansadmitallnewcasesofacutepericarditistothehospital,butthismaynotbenecessary.Apatientwithuncomplicatedacutepericarditiscanundergoinitialevaluationinasamedayhospitalfacilityorclinic,althoughoutpatientfollowup

Patientswithsymptomaticeffusionsandevidenceofcardiactamponadeshouldundergopromptpericardialdrainage.(See"Cardiactamponade".)

Whenasignificantpericardialeffusionispresent,adiagnosticpericardiocentesisisindicatedifaspecificetiologyishighlysuspected,anddiagnosiscannotbereachedbyothermeans.Theinvestigationisespeciallyindicatedwhenaneoplasticorbacterialetiologyissuspectedbecauseadefinitediagnosiscanonlybemadebyidentificationoftheetiologicagentinthepericardialfluid.Fluidsamplesshouldbesentforcytology,tumormarkers,gramstain,bacterialcultures,and,iftuberculosisissuspected,polymerasechainreactiontestingfortuberculosis.(See"Diagnosisandtreatmentofpericardialeffusion"and"Pericardialdiseaseassociatedwithmalignancy".)

Pericardiocentesismaybeconsideredalsoforlargeeffusionsrefractorytomedicaltreatment[36].

Effusionsthataresmalltomoderateinsizeanddonotcausehemodynamiccompromise(ie,cardiactamponade)generallydonotrequiredrainage,unlessasampleoftheeffusionisnecessaryfordiagnosticpurposes.Moreover,pericardiocentesisperformedpercutaneouslyhasasignificantlyhighercomplicationrateiftheeffusionisnotlarge.



isrequired[6,10,32,35].Ontheotherhand,patientswithhighriskfeaturesareatincreasedriskofshorttermcomplicationsandhaveahigherlikelihoodofaspecificdisease[10,32].Hospitaladmissionisindicatedforhighriskpatientsinordertoinitiateappropriatetherapyandathoroughetiologicevaluation.

Featuresofacutepericarditisassociatedwithahigherriskinclude[10,32]:

Inonereportof300consecutivepatientswithacutepericarditis,15percentweredeemedhighriskatpresentationandwerehospitalized[10].Intheremaining85percentofpatientswhowerelowrisk,outpatientaspirintherapywaseffectivein87percent,andnoneofthesepatientshadaseriouscomplication(eg,cardiactamponade)atameanfollowupof38months.

Althoughchronicuseofglucocorticoidsshouldnotbeconsideredasariskfactorinageneralpopulationofpatientswithacutepericarditis,theywereassociatedwithanincreasedrateofcomplicationsinidiopathicorviralpericarditis[32].Glucocorticoidtherapygivenintheindexattackmayincreasethechanceofrecurrence,probablybecauseofitsdeleteriouseffectonviralreplicationandclearance.(See"Recurrentpericarditis",sectionon'Predictorsofrecurrence'.)

Gendermayalsopredictthelikelihoodofcomplications.Inaseriesof453consecutivecasesofacutepericarditis,womenwereatincreasedriskofcomplications(hazardration1.65,95%CI1.08to2.52)[32].Apossibleexplanationofthisfindingisthehigherfrequencyofautoimmuneetiologies(aboveallconnectivetissuediseases)inwomen.

PROGNOSISPatientswithacuteidiopathicorviralpericarditishaveagoodlongtermprognosis.Cardiactamponaderarelyoccursinpatientswithacuteidiopathicpericarditisandismorecommoninpatientswithaspecificunderlyingetiologysuchasmalignancy,tuberculosis,orpurulentpericarditis.Constrictivepericarditismayoccurinabout1percentofpatientswithacuteidiopathicpericarditis,andisalsomorecommoninpatientswithaspecificetiology.(See"Constrictivepericarditis".)

Approximately15to30percentofpatientswithidiopathicacutepericarditiswhoarenottreatedwithcolchicinedevelopeitherrecurrentorincessantdisease.Immunemechanismsappeartobeofprimaryimportanceinthemajorityofcases,andtheterm"chronicautoreactive"pericarditishasbeenused.Riskfactorsforrecurrentpericarditisincludelackofresponsetononsteroidalantiinflammatorydrugs,theneedforcorticosteroidtherapy,andinappropriatepericardiotomyorcreationofapericardialwindow.Thepathogenesis,course,andtreatmentofrecurrentpericarditisarediscussedseparately.(See"Recurrentpericarditis".)

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5 to6gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10 to12 gradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthekeyword(s)ofinterest.)

Fever(>38C[100.4F])andleukocytosisEvidencesuggestingcardiactamponadeAlargepericardialeffusion(ie,anechofreespaceofmorethan20mm)ImmunosuppressedstateAhistoryoftherapywithvitaminKantagonists(eg,warfarin)AcutetraumaFailuretorespondwithinsevendaystoNSAIDtherapyElevatedcardiactroponin,whichsuggestsmyopericarditis

th th

th th

Basicstopics(see"Patientinformation:Pericarditisinadults(TheBasics)")


http://www.uptodate.com/contents/clinicalpresentationanddiagnosticevaluationofacutepericarditis?topicKey=CARD%2F4940&elapsedTimeMs=7& 10/26

SUMMARYANDRECOMMENDATIONS

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

REFERENCES

1. ImazioM.Contemporarymanagementofpericardialdiseases.CurrOpinCardiol201227:308.2. SpodickDH.Acutecardiactamponade.NEnglJMed2003349:684.3. KytV,SipilJ,RautavaP.Clinicalprofileandinfluencesonoutcomesinpatientshospitalizedforacute

BeyondtheBasicstopic(see"Patientinformation:Pericarditis(BeyondtheBasics)")

Acutepericarditis(inflammationofthepericardialsac)isthemostcommondisorderofthepericardiumandisseeninabout0.1percentofhospitalizedpatientsand5percentofpatientsadmittedtotheEmergencyDepartmentfornonischemicchestpain.(See'Epidemiology'above.)

Idiopathiccases,mostofwhichareprobablyviralinetiology,arethemostcommoncausesofacutepericarditis.Otheretiologiesofacutepericarditisincludeanybacterialinfections,malignancy,andautoimmunedisorders(table3).Thedistributionofetiologiesvarieswithgeographyandtypeofclinicalsetting(communityhospitalversustertiaryreferralcenter).(See'Epidemiology'above.)

Thediagnosisofacutepericarditisisusuallysuspectedbasedonahistoryofcharacteristicpleuriticchestpain,especiallywhenapericardialfrictionrubispresent.Pericarditisshouldalsobesuspectedinapatientwithpersistentfeverandpericardialeffusionornewunexplainedcardiomegaly.(See'Clinicalfeatures'above.)

Theevaluationofapatientwithsuspectedacutepericarditisincludesbloodwork(assessingformarkersofinflammationormyocardialdamage),chestradiography,electrocardiography,andechocardiography.Theelectrocardiogram(ECG)isoftenthemosthelpfultestintheevaluationofpatientswithsuspectedacutepericarditis.Echocardiographyisoftennormal,butcanbeanessentialpartoftheevaluationifthereisevidenceofanassociatedpericardialeffusionand/orsignsofcardiactamponade.(See'Diagnosis'aboveand'Evaluation'above.)

Acutepericarditisisdiagnosedbythepresenceofatleasttwoofthefollowingcriteria(table2):(See'Diagnosis'above.)

Typicalchestpain(sharpandpleuritic,improvedbysittingupandleaningforward).(See'Chestpain'above.)

Pericardialfrictionrub(asuperficialscratchyorsqueakingsoundbestheardwiththediaphragmofthestethoscopeovertheleftsternalborder)(movie1).(See'Pericardialfrictionrub'above.)

Suggestivechangesontheelectrocardiogram(typicallywidespreadSTsegmentelevation)(waveform1).(See'Electrocardiogram'above.)

Neworworseningpericardialeffusion.(See'Echocardiogram'above.)

Becauseoftherelativelybenigncourseassociatedwiththecommoncausesofpericarditis,itisnotnecessarytosearchfortheetiologyinallpatients.Initialeffortsshouldfocusuponexcludingasignificanteffusionortamponadeandtheidentificationofpatientsinwhomamorecomprehensiveevaluationshouldbeperformedtoexcludecausesthatrequirespecifictherapy(eg,malignancy,tuberculosisorpurulentpericarditis).(See'Identifyingtheetiology'above.)

Apatientwithuncomplicatedacutepericarditiscanundergoinitialevaluationinasamedayhospitalfacilityorclinic,althoughoutpatientfollowupisrequired.Conversely,patientswithhighriskfeatures(ie,highfever,largepericardialeffusion,cardiactamponade,failuretorespondtoempiricantiinflammatorytherapy)areatincreasedriskofshorttermcomplicationsandhaveahigherlikelihoodofaspecificdisease.Hospitaladmissionisindicatedforhighriskpatientsinordertoinitiateappropriatetherapyandthoroughetiologicevaluation.(See'Determinationofriskandneedforhospitalization'above.)



pericarditis.Circulation2014130:1601.4. ImazioM,CecchiE,DemichelisB,etal.Myopericarditisversusviraloridiopathicacutepericarditis.

Heart200894:498.5. TroughtonRW,AsherCR,KleinAL.Pericarditis.Lancet2004363:717.6. LangeRA,HillisLD.Clinicalpractice.Acutepericarditis.NEnglJMed2004351:2195.7. LittleWC,FreemanGL.Pericardialdisease.Circulation2006113:1622.8. HeidenreichPA,EisenbergMJ,KeeLL,etal.PericardialeffusioninAIDS.Incidenceandsurvival.

Circulation199592:3229.9. ChenY,BrennesselD,WaltersJ,etal.Humanimmunodeficiencyvirusassociatedpericardialeffusion:

reportof40casesandreviewoftheliterature.AmHeartJ1999137:516.10. ImazioM,DemichelisB,ParriniI,etal.Dayhospitaltreatmentofacutepericarditis:amanagement

programforoutpatienttherapy.JAmCollCardiol200443:1042.11. SpodickDH.Acutepericarditis:currentconceptsandpractice.JAMA2003289:1150.12. Spodick,DH.Acute,clinicallynoneffusive("dry")pericarditis.In:SpodickDH:ThePericardium:A

ComprehensiveTextbook,MarcelDekker,NewYork1997.p.94113.13. SpodickDH.Pericardialrub.Prospective,Multipleobserverinvestigationofpericardialfrictionin100

patients.AmJCardiol197535:357.14. ZayasR,AnguitaM,TorresF,etal.Incidenceofspecificetiologyandroleofmethodsforspecific

etiologicdiagnosisofprimaryacutepericarditis.AmJCardiol199575:378.15. RutskyEA,RostandSG.Pericarditisinendstagerenaldisease:Clinicalcharacteristicsand

management.SeminDial19892:25.16. Spodick,DH.ThePericardium:AComprehensiveTextbook,MarcelDekker,NewYork1997.p.4664.17. ChouTC.Electrocardiographyinclinicalpractice,WBSaundersCompany,Philadelphia1996.18. SpodickDH.Arrhythmiasduringacutepericarditis.Aprospectivestudyof100consecutivecases.

JAMA1976235:39.19. ChouTC.ElectrocardiographyinClinicalPractice:AdultsandPediatrics,4thed,WBSaunders,

Philadelphia1996.20. KlatskyAL,OehmR,CooperRA,etal.Theearlyrepolarizationnormalvariantelectrocardiogram:

correlatesandconsequences.AmJMed2003115:171.21. SpodickDH.Differentialcharacteristicsoftheelectrocardiograminearlyrepolarizationandacute

pericarditis.NEnglJMed1976295:523.22. GinztonLE,LaksMM.Thedifferentialdiagnosisofacutepericarditisfromthenormalvariant:new

electrocardiographiccriteria.Circulation198265:1004.23. ImazioM,DemichelisB,CecchiE,etal.CardiactroponinIinacutepericarditis.JAmCollCardiol2003

42:2144.24. KleinAL,AbbaraS,AglerDA,etal.AmericanSocietyofEchocardiographyclinicalrecommendationsfor

multimodalitycardiovascularimagingofpatientswithpericardialdisease:endorsedbytheSocietyforCardiovascularMagneticResonanceandSocietyofCardiovascularComputedTomography.JAmSocEchocardiogr201326:965.

25. CheitlinMD,ArmstrongWF,AurigemmaGP,etal.ACC/AHA/ASE2003guidelinefortheclinicalapplicationofechocardiographywww.acc.org/qualityandscience/clinical/statements.htm(AccessedonAugust24,2006).

26. PermanyerMiraldaG,SagristSauledaJ,SolerSolerJ.Primaryacutepericardialdisease:aprospectiveseriesof231consecutivepatients.AmJCardiol198556:623.

27. ImazioM,BobbioM,CecchiE,etal.Colchicineinadditiontoconventionaltherapyforacutepericarditis:resultsoftheCOlchicineforacutePEricarditis(COPE)trial.Circulation2005112:2012.

28. ImazioMandTrincheroR.Myopericarditis:Etiology,management,andprognosis.IntJCardiol200823:127.

29. HalsellJS,RiddleJR,AtwoodJE,etal.MyopericarditisfollowingsmallpoxvaccinationamongvaccinianaiveUSmilitarypersonnel.JAMA2003289:3283.

30. CassimatisDC,AtwoodJE,EnglerRM,etal.Smallpoxvaccinationandmyopericarditis:aclinicalreview.JAmCollCardiol200443:1503.

31. ImazioM,TrincheroR.Triageandmanagementofacutepericarditis.IntJCardiol2007118:286.



32. ImazioM,CecchiE,DemichelisB,etal.Indicatorsofpoorprognosisofacutepericarditis.Circulation2007115:2739.

33. MaischB,RistiAD.Theclassificationofpericardialdiseaseintheageofmodernmedicine.CurrCardiolRep20024:13.

34. PermanyerMiraldaG.Acutepericardialdisease:approachtotheaetiologicdiagnosis.Heart200490:252.

35. ImazioM,TrincheroR.Clinicalmanagementofacutepericardialdisease:areviewofresultsandoutcomes.ItalHeartJ20045:803.

36. ImazioM,SpodickDH,BrucatoA,etal.Controversialissuesinthemanagementofpericardialdiseases.Circulation2010121:916.

37. ImazioM,BrucatoA,DerosaFG,etal.Aetiologicaldiagnosisinacuteandrecurrentpericarditis:whenandhow.JCardiovascMed(Hagerstown)200910:217.

Topic4940Version16.0



GRAPHICS

Majorcausesofpericardialdisease

IdiopathicInmostcaseseries,themajorityofpatientsarenotfoundtohaveanidentifiablecauseofpericardialdisease.Frequentlysuchcasesarepresumedtohaveaviralorautoimmuneetiology.

InfectionsViralCoxsackievirus,echovirus,adenovirus,EBV,CMV,influenza,varicella,rubella,HIV,hepatitisB,mumps,parvovirusB19,vaccina(smallpoxvaccination)

BacterialStaphylococcus,Streptococcus,pneumococcus,Haemophilus,Neisseria(gonorrhoeaeormeningitidis),Chlamydia(psittaciortrachomatis),Legionella,tuberculosis,Salmonella,Lymedisease

Mycoplasma

FungalHistoplasmosis,aspergillosis,blastomycosis,coccidiodomycosis,actinomycosis,nocardia,candida

ParasiticEchinococcus,amebiasis,toxoplasmosis

Infectiveendocarditiswithvalveringabscess

Radiation

NeoplasmMetastaticLungorbreastcancer,Hodgkin'sdisease,leukemia,melanoma

PrimaryRhabdomyosarcoma,teratoma,fibroma,lipoma,leiomyoma,angioma

Paraneoplastic

CardiacEarlyinfarctionpericarditis

Latepostcardiacinjurysyndrome(Dressler'ssyndrome),alsoseeninothersettings(eg,postmyocardialinfarctionandpostcardiacsurgery)

Myocarditis

Dissectingaorticaneurysm

TraumaBlunt

Penetrating

IatrogenicCatheterandpacemakerperforations,cardiopulmonaryresuscitation,postthoracicsurgery

AutoimmuneRheumaticdiseasesIncludinglupus,rheumatoidarthritis,vasculitis,scleroderma,mixedconnectivedisease

OtherGranulomatosiswithpolyangiitis(Wegener's),polyarteritisnodosa,sarcoidosis,inflammatoryboweldisease(Crohn's,ulcerativecolitis),Whipple's,giantcellarteritis,Behcet'sdisease,rheumaticfever



DrugsProcainamide,isoniazid,orhydralazineaspartofdruginducedlupus

OtherCromolynsodium,dantrolene,methysergide,anticoagulants,thrombolytics,phenytoin,penicillin,phenylbutazone,doxorubicin

MetabolicHypothyroidismPrimarilypericardialeffusion

Uremia

Ovarianhyperstimulationsyndrome

Adaptedfrom:ShabetaiR.Diseasesofthepericardium.In:Hurst'sTheHeart,8thed,SchlantRC,AlexanderRW,etal(Eds).

Graphic67851Version6.0



Cardiacauscultationsupineandleaningforward

Auscultationofthepericardium:Toelicitpericardialrubs,thepatientisinvitedtoleanforward(A)orrestonelbowsandknees(B).Bothphysicalmaneuversincreasethecontactofvisceralandparietalpericardium.

Reproducedfrom:Heart,ImazioM.Pericardialinvolvementinsystemicinflammatorydiseases,97:1882,Copyright2011,withpermissionfromBMJPublishingGroupLtd.




Electrocardiogram(ECG)inpericarditis

ElectrocardiograminacutepericarditisshowingdiffuseupslopingSTsegmentelevationsseenbesthereinleadsII,III,aVF,andV2toV6.ThereisalsosubtlePRsegmentdeviation(positiveinaVR,negativeinmostotherleads).STsegmentelevationisduetoaventricularcurrentofinjuryassociatedwithepicardialinflammationsimilarly,thePRsegmentchangesareduetoanatrialcurrentofinjurywhich,inpericarditis,typicallydisplacesthePRsegmentupwardinleadaVRanddownwardinmostotherleads.

CourtesyofAryGoldberger,MD.


NormalECG



Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPRintervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.





Electrocardiogram(ECG)inanevolvinganteriormyocardialinfarction

ElectrocardiogramshowsfindingstypicalofanevolvingQwaveanteriorMI:lossofRwavesinleadsV1toV3,STsegmentelevationsinV2toV4,andTwaveinversionsinleadsI,aVL,andV2toV5.Sinusbradycardia(55beats/min)ispresentduetoconcurrenttherapywithabetablocker.



NormalECG

Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPRintervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.





Hyperacute(peaked)Twaves

HyperacuteTwavesare>5mminthelimbleads,andusually>10mmintheprecordialleads.Theyhaveapeaked,symmetricmorphology.




NormalECG

Normalsinusrhythmatarateof71beats/min,aPwaveaxisof45,andaPRintervalof0.15sec.

CourtesyofMortonArnsdorf,MD.




Earlyrepolarization12leadECG

EarlyrepolarizationmanifestasinferiorJpointslurringandlateralJpointnotching,each>1mmintwocontiguousleads.




Chestxrayofapericardialeffusion

Cardiomegalyduetoamassivepericardialeffusion.Atleast200mLofpericardialfluidmustaccumulatebeforethecardiacsilhouetteenlarges.

CourtesyofMassimoImazio,MD,FESC.




Diagnosticcriteriaforacutepericarditisandmyopericarditisintheclinicalsetting

Acutepericarditis(atleast2criteriaof4shouldbepresent)*:1.Typicalchestpain

2.Pericardialfrictionrub

3.SuggestiveECGchanges(typicallywidespreadSTsegmentelevation)

4.Neworworseningpericardialeffusion

Myopericarditis:1.Definitediagnosisofacutepericarditis,PLUS

2.Suggestivesymptoms(dyspnea,palpitations,orchestpain)andECGabnormalitiesbeyondnormalvariants,notdocumentedpreviously(ST/Tabnormalities,supraventricularorventriculartachycardiaorfrequentectopy,atrioventricularblock),ORfocalordiffusedepressedLVfunctionofuncertainagebyanimagingstudy

3.Absenceofevidenceofanyothercause

4.Oneofthefollowingfeatures:evidenceofelevatedcardiacenzymes(creatinekinaseMBfraction,ortroponinIorT),ORnewonsetoffocalordiffusedepressedLVfunctionbyanimagingstudy,ORabnormalimagingconsistentwithmyocarditis(MRIwithgadolinium,gallium67scanning,antimyosinantibodyscanning)

Casedefinitionsformyopericarditisinclude:Suspectedmyopericarditis:criteria1plus2and3

Probablemyopericarditis:criteria1,2,3,and4

Confirmedmyopericarditis :histopathologicevidenceofmyocarditisbyendomyocardialbiopsyoronautopsy

*Pericardialeffusionconfirmstheclinicaldiagnosisbutitsabsencedoesnotexcludeit.Inclinicalpracticeaconfirmeddiagnosiswouldrequireanendomyocardialbiopsythatisnotwarrantedinselflimitedcaseswithpredominantpericarditis.

Reproducedwithpermissionfrom:ImazioM,TrincheroR.Triageandmanagementofacutepericarditis.IntJCardiol2006,doi:10.1016/j.ijcard.2006.07.100.Copyright2006Elsevier.




Acutepericarditisetiology:Datafrompublishedclinicalstudieswithunselectedpopulations

PermanyerMiraldaG.

etal.(n=231)

ZayasR.etal.

(n=100)

ImazioM.etal.

(n=453)

Years 19771983 19911993 19962004

Location Spain Spain Italy

Idiopathic 199(86.0percent) 78(78.0percent)

377(83.2percent)

Specificetiology 32(14.0percent) 22(22.0percent)

76(16.8percent)

Neoplastic 13(5.6percent) 7(7.0percent) 23(5.1percent)

Tuberculosis 9(3.9percent) 4(4.0percent) 17(3.8percent)

Autoimmuneetiologies

4(1.7percent) 3(3.0percent) 33(7.3percent)

Purulent 2(0.9percent) 1(1.0percent) 3(0.7percent)

Datafrom:PermanyerMiraldaG,SagristaSauledaJ,SolerSolerJ.Primaryacutepericardialdisease:Aprospectiveseriesof231consecutivepatients.AmJCardiol198556:623ZayasR,AnguitaM,TorresF,etal.Incidenceofspecificetiologyandroleofmethodsforspecificetiologicdiagnosisofprimaryacutepericarditis.AmJCardiol199575:378ImazioM,CecchiE,DemichelisB,etal.Indicatorsofpoorprognosisofacutepericarditis.Circulation2007115:2739.




Indicationsforinvasiveworkupinacutepericarditis

Pericardiocentesis:1.Cardiactamponade

2.Moderatetolargeeffusionsrefractorytomedicaltherapyandwithseveresymptoms

3.Suspectedbacterialorneoplasticpericarditis

Pericardialbiopsyandpericardioscopy(targetedbiopsyinspecializedcenter):1.Relapsingcardiactamponade

2.Suspectedbacterialorneoplasticpericarditis

3.Worseningpericarditis(despitemedicaltherapy)withoutaspecificdiagnosis

CourtesyofDr.MassimoImazio.




Disclosures:MassimoImazio,MD,FESCNothingtodisclose.MartinMLeWinter,MDNothingtodisclose.BrianCDowney,MD,FACCNothingtodisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy

Disclosures

Documents

Clinical Presentation and Diagnostic Evaluation of Acute Pericarditis