### Date : 2024-11-03 14:14 ### Topic : Acute pericarditis #cardiology ---- **Acute Pericarditis** is an inflammation of the pericardium, the thin, double-layered sac that surrounds the heart. This condition can lead to chest pain, fever, and other symptoms, often resembling a heart attack. Although most cases are mild and self-limiting, some can lead to complications like pericardial effusion or, rarely, cardiac tamponade. ### Causes of Acute Pericarditis Acute pericarditis can be caused by a variety of factors, including: 1. **Infections**: - **Viral**: The most common cause, especially **Coxsackievirus**, **echovirus**, **adenovirus**, and **COVID-19**. - **Bacterial**: Less common but more severe, often caused by **tuberculosis**, **Staphylococcus**, or **Streptococcus**. - **Fungal and Parasitic**: Rare, typically in immunocompromised individuals. 2. **Non-Infectious Causes**: - **Autoimmune Diseases**: Conditions like **systemic lupus erythematosus (SLE)**, **rheumatoid arthritis**, and **scleroderma**. - **Post-Myocardial Infarction**: Known as [[Dressler’s syndrome]], which occurs days to weeks after a heart attack. - **Uremia**: Seen in patients with severe kidney failure. - **Trauma or Surgery**: Chest trauma, heart surgery, or invasive cardiac procedures can inflame the pericardium. - **Malignancy**: Primary or metastatic cancers (e.g., lung or breast cancer) can affect the pericardium. 3. **Idiopathic**: - In many cases, no specific cause is identified, and it is termed idiopathic pericarditis, though it is often presumed to be viral. ### Pathophysiology - **Inflammatory Response**: The pericardium becomes inflamed, leading to the infiltration of immune cells and the release of inflammatory mediators. - **Pericardial Effusion**: Fluid may accumulate in the pericardial sac due to inflammation, causing a pericardial effusion. If this fluid accumulates rapidly, it can lead to **cardiac tamponade**, a medical emergency where the heart is compressed and cannot fill properly. ### Symptoms of Acute Pericarditis The main symptoms include: 1. **Chest Pain**: - **Sharp and Pleuritic**: Often worsens with inspiration or coughing. - **Relieved by Sitting Up and Leaning Forward**: This is a classic finding, as it reduces the pressure on the pericardium. - Pain often radiates to the shoulders, back, or neck, resembling myocardial infarction pain. 2. **Other Symptoms**: - **Fever**: Mild to moderate fever is common, especially in infectious pericarditis. - **Dyspnea**: Shortness of breath, particularly with pericardial effusion or when lying flat. - **Palpitations**: Sometimes caused by associated arrhythmias. ### Physical Examination Findings - **Pericardial Friction Rub**: - A characteristic scratching or rubbing sound heard on auscultation, best heard at the left sternal border with the patient leaning forward. - The friction rub is often triphasic, corresponding to atrial systole, ventricular systole, and early ventricular diastole. ### Diagnosis of Acute Pericarditis Diagnosis is based on clinical presentation, physical examination, EKG, and imaging. The diagnosis is often confirmed when two or more of the following criteria are present: 1. **Electrocardiogram (ECG)**: - **Diffuse ST Elevation**: Concave, upward-sloping ST elevation seen in multiple leads (except aVR and V1, where ST depression is common). - **PR Segment Depression**: Often seen in leads with ST elevation, except aVR, where PR elevation may be noted. - **No Reciprocal Changes**: Unlike myocardial infarction, reciprocal ST depressions are usually absent in pericarditis. 2. **Echocardiography**: - Used to detect any associated **pericardial effusion** and assess for signs of cardiac tamponade. - It is especially helpful if there is suspicion of a large effusion or complications. 3. **Chest X-Ray**: - Typically normal unless a significant pericardial effusion is present, which can cause a "water-bottle" shaped cardiac silhouette. 4. **Blood Tests**: - **Inflammatory Markers**: Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). - **Troponin**: Can be mildly elevated if there is associated myocarditis. 5. **Other Tests**: - **Pericardial Fluid Analysis**: If there is a large effusion, fluid can be aspirated to identify infectious or malignant causes. - **CT or MRI**: Occasionally used for detailed imaging, particularly in cases where constrictive pericarditis is suspected or to evaluate inflammation. ### Treatment of Acute Pericarditis Treatment depends on the severity and underlying cause, but it typically includes: 1. **Anti-Inflammatory Medications**: - **NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)**: First-line therapy for acute pericarditis, typically ibuprofen or aspirin. - **Colchicine**: Often added to reduce recurrence rates and is given for 3 months. - **Corticosteroids**: Reserved for refractory cases or cases related to autoimmune diseases. They are usually avoided initially due to increased risk of recurrence. 2. **Treatment of Underlying Cause**: - **Antibiotics** for bacterial pericarditis, **antitubercular therapy** for tuberculosis, and specific therapies for autoimmune-related cases. 3. **Pericardiocentesis**: - Required in cases of large effusion causing cardiac tamponade, where fluid is drained to relieve pressure on the heart. 4. **Avoid Physical Activity**: - Patients are advised to restrict physical activity during the acute phase to reduce symptoms and prevent recurrence. ### Complications of Acute Pericarditis - **Pericardial Effusion**: Fluid buildup in the pericardium, which can sometimes progress to cardiac tamponade if severe and left untreated. - **Cardiac Tamponade**: A life-threatening condition where accumulated fluid compresses the heart, impeding its ability to fill and pump effectively. - **Chronic or Recurrent Pericarditis**: Some patients may experience repeated episodes of pericarditis, leading to chronic inflammation. - **Constrictive Pericarditis**: Rarely, long-standing pericarditis can cause the pericardium to become scarred and thickened, restricting heart movement and leading to heart failure symptoms. ### Summary - **Acute Pericarditis** is an inflammation of the pericardium with causes ranging from viral infections to autoimmune diseases. - **Symptoms** include sharp chest pain relieved by leaning forward, fever, and dyspnea. - **Diagnosis** is based on clinical criteria, with diffuse ST elevation and PR depression on EKG being characteristic findings. - **Treatment** involves NSAIDs and colchicine, with corticosteroids for refractory or autoimmune-related cases. - **Complications** include pericardial effusion, cardiac tamponade, and chronic or recurrent pericarditis. Acute pericarditis generally has a good prognosis with appropriate treatment but requires careful monitoring for complications, especially if the patient develops symptoms of tamponade or recurrent episodes. ### Reference: - ### Connected Documents: -