Pericarditis

Pericarditis
Classification and external resources
File:PericarditisECG.JPG An ECG showing pericarditis. Note the ST elevation in multiple leads with slight reciprocal ST depression in aVR.
ICD-10	I01.0, I09.2, I30.-I32.
ICD-9	420.90
DiseasesDB	9820
MedlinePlus	000182
eMedicine	med/1781 emerg/412
MeSH	D010493

Pericarditis is an inflammation (-itis) of the pericardium (the fibrous sac surrounding the heart).

Classification

Pericarditis can be classified according to the composition of the inflammatory exudate.

Types include:

• serous
• purulent
• fibrinous
• caseous
• hemorrhagic
• Post infarction

Pericardiocentesis can be performed to permit analysis of the pericardial fluid.

Acute vs. chronic

Acute pericarditis is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or even as a result of a heart attack (acute myocardial infarction).

One form of chronic pericarditis is constrictive pericarditis.

• Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)

Clinical presentation

Chest pain, which can expand and radiate to the back, and which is relieved by sitting up forward and worsened by lying down, is a common symptom. The pain, which may resemple the pain of angina pectoris or heart attack, may also worsen during a deep breath or standing up too quickly. This pain is the classical presentation (meaning it is the most common symptom and occurs as a feature in many, or even a majority, of the cases known to medicine). Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack), and vice versa, and as said above, a heart attack can cause noninfectious pericarditis to occur as a complication.

The classic sign of pericarditis is a friction rub. Other signs include diffuse ST-elevation and PR-depression on ECG in all leads except aVR and V1; cardiac tamponade (pulsus paradoxus with hypotension), and congestive heart failure (elevated jugular venous pressure with peripheral edema).

Since the mid-19th Century, retrospective diagnosis of pericarditis has been made upon the finding of adhesions of the pericardium. When pericarditis is diagnosed clinically, the underlying cause is often never known; it may be discovered in only 16 to 22 percent of patients with acute pericarditis.

Causes

Infectious

Pericarditis may be caused by viral, bacterial, or fungal infection. The most common viral pathogen (the virus that causes the most known cases of pericarditis) has traditionally been considered coxsackievirus based on studies in children from the 1960s, but recent data suggest adults are most commonly afflicted with cytomegalovirus, herpesvirus, and HIV (the weakening of the body and its immune system which these viruses and other organisms cause makes the patient's heart vulnerable to infection). Pneumococcus or tuberculous pericarditis are the most common bacterial forms. Fungal pericarditis is usually due to histoplasmosis, or in immunocompromised hosts Aspergillus, Candida, and Coccidioides.

Other

• Idiopathic: No identifiable etiology found after routine testing.
• Immunologic conditions including systemic lupus erythematosus (more common among women) or rheumatic fever
• Myocardial Infarction (Dressler's syndrome)
• Trauma to the heart, e.g. puncture, resulting in infection or inflammation
• Uremia (uremic pericarditis)
• Malignancy (as a paraneoplastic phenomenon)
• Side effect of some medications, e.g. isoniazid, cyclosporine, hydralazine
• Radiation induced
• Aortic dissection
• Tetracyclines
• Postpericardiotomy syndrome

Pathophysiology

Complications

Most cases of acute idiopathic pericarditis resolve without complications or recurrence. Complications may include:

• Pericardial effusion
• Constrictive pericarditis
• Cardiac tamponade

Treatment

The treatment in viral or idiopathic pericarditis is with non-steroidal anti-inflammatory drugs. Severe cases may require:

• pericardiocentesis
• antibiotics
• steroids
• colchicine
• in rare cases, surgery

References

General References

• Troughton RW, Asher CR and Klein AL. Pericarditis, Lancet 2004;363:717-27. http://www.ncbi.nlm.nih.gov/pubmed/15001332
• Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal 2004;25:587-610. http://eurheartj.oxfordjournals.org/cgi/content/full/25/7/587

External links

• Pericarditis - Cleveland Clinic
• Pericarditis - National Library of Medicine
• Pericarditis - National Heart Lung Blood Institute

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