Pericarditis

Key points

• Pericarditis is an inflammatory or infective disease of the pericardium which may be acute or chronic
• Acute form typically presents with chest pain relieved by leaning forward, a pathognomonic friction rub, and widespread ST-segment elevation on electrocardiogram (ECG)
• Chronic form is insidious, painless, characterized by dyspnea and fatigue and accompanied by signs of right and/or left heart failure
• Cardiac tamponade, a complication of pericarditis, is a medical emergency which presents as a classic triad of raised jugular venous pressure, pulsus paradoxus, and hypotension and requires immediate surgical intervention

Background

Description

Acute pericarditis:

• Inflammation present for less than 3 months
• Chest pain relieved by leaning forward
• Central chest pain radiating to the neck and shoulders, particularly to the left side
• Pericardial friction rub, best heard with patient leaning forward in expiration, is pathognomonic
• Characteristic ECG changes of widespread concave-upward ST-segment elevation not corresponding to a coronary artery territory, often associated with PR depression (except lead aVL) reflecting atrial involvement
• When untreated, may progress to chronic pericarditis

Chronic pericarditis:

• Inflammation that has lasted for more than 3 months
• Insidious, painless, characterized by dyspnea and fatigue, until a large pericardial effusion or onset of pericardial constriction causes right-sided heart failure and hemodynamic compromise

Epidemiology

Incidence and prevalence:

• True incidence in nonselected population is unknown
• Approximately 6% of patients have signs of pericarditis on postmortem examination
• Hospital diagnosis for pericarditis accounts for approximately 1/1,000 admissions

Demographics:

• Age: More common in adults
• Gender: More common in men
• Race: Tuberculous pericarditis is more common in black patients with HIV infection
• Geography: Histoplasmosis pericarditis is endemic in Mississippi and Ohio river valleys and in western Appalachian Mountains. Coccidioidomycosis pericarditis is endemic in the U.S. southwest and Argentina

Causes and risk factors

Causes

Common causes:

• Viral: coxsackievirus and echovirus
• Autoreactive: various autoimmune and reactive systemic disorders including connective tissue disease: rheumatoid arthritis (17% of patients within 3 years of diagnosis), systemic lupus erythematosus (50% of patients at some stage in the disease), ankylosing spondylitis, Reiter syndrome, panarteritis nodosa
• Early after myocardial infarction: Up to 20% of patients with transmural acute myocardial infarction develop clinical signs of pericarditis at 2 to 4 days postinfarct, often associated with low-grade fever. This is usually self-limiting and clinically not significant
• Late post-myocardial infarction pericarditis (Dressler syndrome): now disputed as a separate entity and regarded as a severe, prolonged form of early post-myocardial infarction pericarditis
• Uremia: Up to 20% of uremic patients develop signs of pericarditis, particularly in the first 3 months of dialysis; one-fifth will go on to develop cardiac tamponade
• Metastatic disease: most commonly breast, lung, leukemia, Hodgkin lymphoma
• Post-traumatic: for example, after blunt chest injury or cardiac surgery
• Postsurgical/procedural: following cardio-thoracic surgery and electrophysiology procedures (ablation, pacemaker); increasingly common cause of pericarditis
• Postradiation: Five percent of patients develop pericarditis, particularly after radiotherapy for breast cancer and Hodgkin lymphoma
• Chronic water and salt retention states, such as heart failure, hepatic cirrhosis
• Tuberculosis: present in 1% to 2% of patients with tuberculosis and may not be associated with signs of pulmonary tuberculosis
• HIV: multiple pathogeneses, including tuberculosis, fungal infection, viral infection, and Kaposi sarcoma
• Idiopathic: In most patients, the cause of pericarditis is not determined. Presumably, many cases are undiagnosed viral pericarditis in which serologic confirmation of the causative organism has not been obtained will fall into this group

Rare causes:

• Drugs such as hydralazine, procainamide, methysergide, isoniazid, anticoagulants
• Familial Mediterranean fever (familial recurrent polyserositis)
• Bacterial pericarditis due to Staphylococcus or Haemophilus influenzae, particularly in children with septic arthritis
• Fungal pericarditis, endemic histoplasmosis, and coccidioidomycosis
• Myxedema
• Primary pericardial tumors (extremely rare)

Serious causes:

• Purulent pericarditis after pericardiocentesis, surgery, penetrating trauma, and immunosuppression
• Hemorrhagic pericarditis after aortic dissection or myocardial infarction

Risk factors

• Previous acute pericarditis is a predisposing factor to chronic pericarditis

Screening

Summary approach

Not applicable.

Primary prevention

Not applicable.