INDEX

    Pericarditis – Diagnosis

    Cardiovascular, Inflammatory

    Last Updated Aug 09, 2020
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    Context

    • True incidence of pericarditis unknown: 5% of non-ACS “chest pain” ED visits.
    • Cardiac tamponade can occur in up to 15% of cases.
    • Important to distinguish from ACS.
    • Inflammatory condition of the pericardium:
      • Infectious etiologies
        • Most common cause is viral or idiopathic as etiologic agent is rarely identified.
        • Consider tuberculosis if recent travel to an endemic region.
      • Non-infectious etiologies
        • Autoimmune conditions – SLE, RA, scleroderma, sarcoid, vasculitis.
        • Autoinflammatory pericardial syndromes (Dressler syndrome): post myocardial infarction, cardiac surgery or cardiac trauma.
        • Neoplastic: (metastatic: lung>breast>leukaemia and lymphoma>melanoma).
        • Radiation.
        • Metabolic (uremia).
        • Drug-related.
      • Symptoms usually last 4-6 weeks but other forms exist
        • Incessant pericarditis: up to 3 months.
        • Recurrent/relapsing pericarditis: symptoms recur after a symptom-free period.
        • Chronic pericarditis: symptoms > 3 months.

    Clinical Presentation

    History

    • Quick onset, sharp chest pain:
      • Pleuritic – worse on inspiration
      • Improves with sitting and leaning forward
      • May radiate to neck, back, shoulder and/or jaw
    • May be preceded by a gastrointestinal or “flu-like” syndrome.

    Physical Examination

    • Tachycardic, tachypneic, fever
    • Friction rub highly specific but only present in 30% of cases
      • Can fluctuate hourly.
      • Heard best at end expiration, with the patient leaning forward.

    ECG

    • There are four stages of ECG evolution in pericarditis, all of which are found in 60% of cases (figure 1).
      • Stage 1 (hours to days): Diffuse ST elevation and PR depression, ST depression in aVR only
      • Stage 2 (within first week): ST and PR segments normalize
      • Stage 3: Diffuse T wave inversion and ECG otherwise normal
      • Stage 4: T waves return to normal (May have indefinite persistence of T wave inversion)

    Figure 1. Progression of ECG changes in acute pericarditis.
    Source: Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(1):76-92. doi:10.1016/j.jacc.2019.11.021

     

    • Pericarditis features that differentiate it from ACS:
      • ST elevation is ‘concave’ up but typically ‘convex’ up in ACS (figure 2)
      • Down sloping T-P segments (“Spodick sign”)
      • Absence of pathologic Q waves
      • Absence of reciprocal ST changes
      • Absence of QRS widening and QT prolongation in leads with ST elevation

    Figure 2. Differentiating convex and concave ST segments. ST segments typically concave in pericarditis and convex in ACS.
    Source: Abdushi S, Veseli A, Abdushi S, Zenelaj F. Differential Diagnosis of ST segment elevation on ECG. UBT Conf Present. 2017;(October 2017). doi:10.33107/ubt-ic.2017.291

     

    • Differentiating pericarditis from benign early repolarization (BER)
      • ST elevation is less than 25% of T-wave amplitude in BER
      • ECG findings are stable over time in BER
      • No PR depression in BER

    Figure 3. Comparison of ECG changes in acute pericarditis, ST elevation MI and benign early repolarization.

    Laboratory Findings

    • WBC, CRP and ESR are likely to be elevated.
    • Troponin may be elevated in 30% – concomitant myocarditis.

    Imaging

    • CXR typically normal
      • Large pericardial effusion is uncommon – cardiomegaly.
    • Transthoracic echocardiography
      • Pericardial effusion in up to 60% of cases, often mild.
      • Wall motion abnormalities suggest ACS rather than pericarditis.

     

    Diagnostic Process

    • Diagnosis of acute pericarditis requires at least two of the four main clinical criteria:
      • Typical chest pain (> 85% cases).
      • Pericardial friction rub (up to 30% cases).
      • New widespread ST elevation or PR depression (up to 60% cases).
      • Pericardial effusion (up to 60% cases).
    • Supportive findings for diagnosis include: elevated inflammatory markers, evidence of pericardial inflammation through CT or CMR (not an ED issue).
    • Diagnostic pericardiocentesis may be considered by cardiology, internal medicine.

    Quality Of Evidence?

    Justification

    Quality of evidence for the use of each diagnostic criteria is low and is based on the consensus of experts or small studies, retrospective studies or registries. The above diagnostic process has not been formally validated in a large scale study, however it remains widely agreed upon and stems from the 2015 European Society of Cardiology guidelines.

    Low

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