Makindo Medical Notes

Related Subjects: | Assessing Breathlessness | Assessing Chest Pain | Pericardial Effusion and Tamponade | Constrictive Pericarditis | Colchicine

ST changes in pericarditis are widespread and typically concave ("saddle-shaped"). There may also be peaked T waves and widespread PR depression.

Management Summary: ECG ST Elevation and PR Depression

Initial Attack First Line: Aspirin or NSAID + Colchicine + exercise restriction Second Line: Low-dose steroids (if unable to take Aspirin or NSAID + Colchicine) after excluding infection Recurrence First Line: Aspirin or NSAID + Colchicine + exercise restriction Second Line: Low-dose steroids (if unable to take Aspirin or NSAID + Colchicine) after excluding infection Third Line: IVIG or Anakinra or Azathioprine Fourth Line: Pericardiectomy

Epidemiology

• Pericarditis accounts for 5% of emergency room admissions for chest pain.
• 5% of patients with pericarditis develop complications such as tamponade or constrictive pericarditis.

Clinical Presentation

• Fever, sweats, malaise, myalgia
• Pleuritic chest pain worsened by inspiration or cough
• Pain is positional—improves when sitting up and leaning forward.
• Friction rub: audible with three components—atrial systole, ventricular systole, and diastole.
• Possible squeaky sound at the left sternal border
• Distant heart sounds suggest a pericardial effusion.

Assess for tamponade: look for distended neck veins, pulsus paradoxus (>10–15 mmHg by blood pressure cuff), and hypotension.

Differential Diagnosis for Chest Pain

• Acute coronary syndrome, myocarditis, aortic dissection
• Pneumonia, pneumonitis, pulmonary embolism
• Gastroesophageal reflux disease (GORD), oesophageal disease
• Musculoskeletal causes

Causes of Pericarditis

• Idiopathic/Post-viral
• Myocardial infarction (MI) or post-MI (Dressler's syndrome)
• Post-pericardiotomy syndrome
• Infectious: bacterial, viral, fungal, HIV
• Malignancy
• Metabolic causes: uremia, dialysis
• Autoimmune: systemic lupus erythematosus, Dressler's syndrome
• Familial Mediterranean fever
• Trauma/Radiation exposure
• Aortic dissection
• Drugs and congenital conditions

Investigations

• Blood Tests: FBC, U&E, LFT, CRP, ESR
• ECG: Widespread ST-segment elevation and PR depression in most leads. The changes evolve over time:
  • Stage 1: Saddle-shaped ST elevation in most leads, PR depression except in aVR (where ST is depressed).
  • Stage 2: ST/PR changes resolve.
  • Stage 3: Widespread T wave inversion.
  • Stage 4: T wave changes resolve.
  The differential diagnosis includes STEMI and early repolarization.
• CRP/ESR: Elevated, indicating inflammation or infection.
• CK/Troponin: Elevated levels suggest concurrent myocarditis (myopericarditis).
• CXR: Usually normal, but may show cardiomegaly in cases of effusion.
• Echocardiogram: Up to 60% of cases may show pericardial effusion, though tamponade is rare.

ECG: Generalized Saddle-shaped ST Elevation

Predictors of Worse Prognosis

• Major:
  • Fever > 38°C
  • Elevated CRP
  • Subacute onset
  • Large pericardial effusion
  • Cardiac tamponade
  • Lack of response to NSAIDs or Aspirin after 1 week
• Minor:
  • Myopericarditis
  • Immunosuppression
  • Trauma
  • Oral anticoagulant use

Management

• Most cases of idiopathic or viral pericarditis are self-limiting and resolve in 2-6 weeks. Severe complications are rare.
• Cardiac tamponade is uncommon, occurring mainly early in the disease course.
• Patients with myopericarditis generally have a good prognosis with no evolution to heart failure.
• Exercise Restriction: Athletes are advised to resume competitive sports only after symptoms have resolved and diagnostic tests (e.g., CRP, ECG, echocardiogram) have normalized. Some experts recommend waiting 3 months.
• Consider Admission if:
  • Non-viral cause
  • Fever > 38°C
  • Effusion > 20 mm
  • Tamponade
  • Trauma
  • Immunosuppression
  • Anticoagulant use
• NSAIDs: Ibuprofen 400-600 mg TDS for 1-2 weeks with a PPI for gastric protection.
• Colchicine: Used for acute and recurrent pericarditis (1 g/day if >70 kg, 0.5 g/day if <70 kg) for 3 months under specialist review.
• Steroids: Consider for more severe cases or if NSAIDs are contraindicated.
• Infection: Treat with appropriate antibiotics (for bacterial causes), antifungals (for fungal causes), or anti-TB therapy (if tuberculosis is suspected).
• Anticoagulants: Assess the risks and benefits, particularly in patients with pericardial involvement, as there is a risk of bleeding into the pericardial space.
• Neoplasia: Consider chemotherapy for malignancy-related pericarditis.

References

• 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases