Updated date:

How Much Do You Know About Pericarditis?

Dr. Khalid is a physician, a researcher, a health writer, and holds a Ph.D. in clinical research.

Classification of Pericarditis

Pericarditis develops due to an accumulation of fluid inside the fibro-elastic/double-layered pericardial sac (1). The purulent, hemorrhagic, or serous nature of pericardial effusion triggers cardiac tamponade by challenging the diastolic filling process. Evidence-based medical literature recognizes the following types of pericarditis (2).

  1. Effusive-constrictive pericarditis
  2. Constrictive pericarditis
  3. Cardiac tamponade
  4. Pericardial effusion
  5. Recurrent pericarditis
  6. Chronic pericarditis
  7. Subacute pericarditis
  8. Acute pericarditis

Clinical History

The history of pericarditis patients includes the following (3).

  1. Left pericardial, substernal, and pleuritic type chest pain with spontaneous onset
  2. The pericarditis pain aggravates in the supine position and reduces in a forward-leaning position
  3. The pleuritic chest pain often radiates to the jaw, arms, neck, and ridge of the trapezius
  4. The cytokine storm due to inflammatory processes triggers myalgia, malaise, and fever
  5. Cardiac tamponade manifests with respiratory difficulty or shortness of breath

Risk Factors

The following conditions/procedures increase the risk of pericarditis and its deleterious complications (2) (4).

  1. Previous history of varicella, mumps, measles, influenza, HIV/AIDS, hepatitis, and coxsackie viruses
  2. Autoimmune disorders
  3. Lung/breast cancers
  4. Radiation therapy
  5. Leukemia
  6. Hodgkin’s disease
  7. Renal failure
  8. Pericardiotomy
  9. Chest trauma
  10. Ablation
  11. Pacemaker status
  12. Catheterization
  13. Aortic dissection
  14. Acute myocardial infarction
  15. Dependence on drugs, including rifampicin, procainamide, phenytoin, penicillin, isoniazid, hydralazine, doxorubicin, and dantrolene

Clinical Assessment

The medical examination concerning pericarditis reveals one or more of the following findings (2) (5).

  1. Tachycardia, tachypnea, pulsus paradoxus, jugular venous distension, and hypotension manifest with cardiac tamponade
  2. Pericardial friction rub transiently progresses in 1-3 phases due to consistent contact of the pericardial sac with the heart during ventricular/atrial systole and rapid ventricular filling
  3. A pericardial friction rub is usually felt across the left sternal border in forward-leaning and sitting positions during expiration
  4. Muffled heart sounds emanate due to cardiac tamponade and pericardial effusion
  5. Pyrexia
  6. Pleural effusions, identified with dullness across the thorax

Differential Assessment

The physician must investigate and rule out the following conditions/risk factors to affirm the diagnosis of pericarditis (6) (7).

  1. Pulmonary embolism
  2. D-dimer elevation
  3. Embolus on pulmonary angiogram
  4. Thrombophilia
  5. Deep vein thrombosis
  6. Pregnancy
  7. Acute coronary syndrome with autonomic symptoms and radiating central chest discomfort/pain
  8. Pneumonia with productive cough, fever, and pleuritic type chest pain
  9. Reproduction of chest (wall) pain via palpation
  10. Elevation of localized/stinging chest (wall) pain with respiration
  11. Gastroesophageal reflux disease/acute gastritis symptoms including dysgeusia, epigastric/lower sternal pain, or burning (with a normal electrocardiogram)
  12. The co-occurrence of back pain with chest pain in a hemodynamically stable patient with aortic dissection

Diagnostic Modalities

The following diagnostic interventions help evaluate pericarditis in various clinical scenarios (8) (9).

  1. The ST-segment elevation/T-wave amplitude ratio (0.25 or above) across V-6 ECG lead will affirm acute pericarditis
  2. Absence of myocardial infarction affirmed by the absence of Q-waves/reciprocal changes in a twelve-lead electrocardiogram
  3. ECG changes may correlate with superficial myocardial inflammation
  4. The appearance of isoelectric ST-segment, diffuse T-wave inversions, PR depression, or diffuse ST elevation
  5. The exclusion of cardiac tamponade warrants echocardiography
  6. Echocardiography findings concerning cardiac tamponade include the collapse of the right ventricle/atrium diastolic chamber
  7. The elevation in leukocyte count, erythrocyte sedimentation rate, and C-reactive protein strengthens the evidence for acute pericarditis
  8. The epicardial inflammation in pericarditis manifests with myocardial injury (affirmed by a marked elevation in cardiac troponins and creatine kinase)
  9. The recurrence of cardiac tamponade or failure of pericardiocentesis warrant subxiphoid pericardial biopsy/drainage for histological/cytological assessment
  10. Pleural fluid assessment (followed by thoracentesis) to investigate mycobacteria and adenosine deaminase
  11. The diagnostic management of purulent pericarditis relies on pericardiocentesis
  12. The assessment of mycobacteria, rheumatoid factor, and antinuclear antibodies is necessary to understand the causes of acute pericarditis (irresponsive to medical management)
  13. Magnetic resonance imaging and computed tomography help investigate inconclusive pericarditis
  14. Chest radiography guides the baseline assessment for pericarditis

Medical Management

The following evidence-based interventions support the medical management of pericarditis (10) (11) (8).

  1. The self-limiting manifestations of acute pericarditis usually require outpatient interventions
  2. The need for hospitalization may arise for the medical management of pericarditis patients with troponin-I elevation, myopericarditis, immune system compromise, history of injury, cardiac tamponade (affirmed by neck vein distension and hypotension), pericardial effusion, and pyrexia
  3. The replacement of NSAID therapy with 0.5mg colchicine (twice daily) may rapidly reduce the symptoms of patients with acute idiopathic/viral pericarditis
  4. The six-hourly administration of 300-800mg ibuprofen or 800mg aspirin until the resolution of pleural effusion may reduce pericardial friction rub, fever, and chest pain in the setting of pericarditis
  5. Regular monitoring of chronic constrictive pericarditis, cardiac tamponade, and pericardial effusion is the key to avoid fatal complications
  6. The adjuvant corticosteroid therapy may reduce the manifestations of idiopathic/uremic/auto-reactive/refractory recurrent pericarditis
  7. The treatment of malignant pericardial effusion relies on the intra-pericardial application of mitoxantrone
  8. Pericardiocentesis facilitates the diagnostic management of purulent pericarditis and therapeutic management of cardiac tamponade

References

1. Willner, D. A.; Goyal, A.; Grigorova, Y.; Kiel, J. Pericardial effusion. In StatPearls; StatPearls Publishing, 2021.

2. Dababneh, E.; Siddique, M. S. Pericarditis. In StatPearls; StatPearls Publishing, 2021.

3. Tingle , L. E.; Molina , D.; Calvert, C. W. Acute pericarditis. American Family Physician 2007, 76 (10), 1509-1514.

4 Andreis, A.; Imazio, M.; Casula, M.; Avondo, S.; Brucato, A. Recurrent pericarditis: an update on diagnosis and management. Intern Emerg Med 2021, 1-8.

5. Sagristà-Sauleda, J.; Mercé, A. S.; Soler-Soler, J. Diagnosis and management of pericardial effusion. World Journal of Cardiology 2011, 3 (5), 135-143.

6. Khandaker, M. H.; Espinosa, R. E.; Nishimura, R. A.; Sinak, L. J.; Hayes , S. N.; Melduni, R. M.; Oh, J. K. Pericardial Disease: Diagnosis and Management. Mayo Clin Proc. 2010, 85 (6), 572–593.

7. Vyas, V.; Goyal , A. Acute Pulmonary Embolism. In StatPearls; StatPearls Publishing, 2021.

8. Ismail, T. E. Acute pericarditis: Update on diagnosis and management. Clin Med 2020, 20 (1), 48-51.

9. Awan, A.; Tiruneh, F.; Wessley, P.; Khan , A.; Iftikhar, H.; Barned, S.; Larbi, D. Acute Pericarditis: Descriptive Study and Etiology Determination in a Predominantly African American Population. Cureus 2017, 9 (7).

10. Lentzsch, S.; Reichardt, P.; Gürtler, R.; Dörken, B. Intrapericardial Application of Mitoxantrone for Treatment of Malignant Pericardial Effusion. Oncology Research and Treatment 1994.

11. Musch, E.; Gremmler, B.; Nitsch, J.; Rieger, J.; Malek, M.; Chrissafidou, A. Intrapericardial instillation of mitoxantrone in palliative therapy of malignant pericardial effusion. Onkologie 2003, 26 (2), 135-139.

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2021 Dr Khalid Rahman

Related Articles