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HWN Suggests

Aye, there’s the rub: Acute Pericarditis

Despite medical school teaching, acute pericarditis presents in a variety of ways. Here’s how it’s traditionally taught:

• Patient history of recent viral syndrome.
• The hallmark is chest pain that is sharp, pleuritic, and improved by sitting up and leaning forward.
• A friction rub may be auscultated on exam (like two pieces of paper rubbing together).
• EKG changes with widespread, diffuse ST elevation.

In reality, it is rarely a perfect picture. Let’s dive into the details.

Chest pain: >95% of patients have it. As noted above, its sharp, retrosternal, and improves with leaning forward. But in reality,…

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Featured

 EM@3AM: Pericarditis

Distinguishing pericarditis from acute MI is the first and most important step. EKG shows: Widespread ST-segment elevation, PR segment depression. ST elevations are all concave, elevation in lead II is > than lead III. ST elevations are more commonly convex with STEMI, while concave upwards ST elevations are more likely to be pericarditis.

Articles of Interest

A Fix for a Stinging Heart - Pericarditis Treatment in the ED

In initial cases of acute pericarditis, patients should be treated with an NSAID plus colchicine. Corticosteroids should be used when a patient has a contraindication to NSAIDs or in cases of systemic inflammatory disease, pregnancy, and renal failure.

Management of Acute and Recurrent Pericarditis

Acute pericarditis remains the most common presentation of pericardial diseases. Although generally benign, pericarditis can be fraught by a significant number of complications and recurrences. According to geographical differences, the etiology varies and so do its prognosis and treatments.

New Diagnostic Criteria for Acute Pericarditis: A Cardiac MRI Perspective

Currently, the diagnosis of acute pericarditis is based on demonstrating at least two of the following four criteria: 1. Non-ischemic chest pain, 2. ECG evidence of PR depression or ST segment deviation, 3. Detection of a pericardial rub on auscultation and 4. Pericardial effusion on 2-D echocardiography. From a practical standpoint, the only reliable criterion is symptomatic chest pain, often making the diagnosis difficult to definitively establish. The chest pain of pericarditis can vary from severe substernal discomfort to a vague "ache". The chest pain is usually positional, not related to exertion and often radiates to the neck, ridge of the trapezius muscle or shoulder. As an ancillary diagnostic tool, laboratory confirmation of an inflammatory process, such as an elevated sed rate, is sometimes used to support the diagnosis of acute pericarditis, but is non-specific.

Pericardial Disease: Diagnosis and Management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis

Pericarditis strikes again

You diagnose pericarditis at your peril! Acute MI is frequently misdiagnosed as pericarditis. Patients with pulmonary embolism or aortic dissection who have normal variant ST elevation are at high risk of being diagnosed with pericarditis when what they have is far more serious!! Pericarditis is a diagnosis of EXCLUSION.

Pericarditis: Plenty of Promise Among the Management Challenges

An ultra-practical update on current care strategies and emerging therapies.

Should all patients with acute pericarditis be treated with colchicine?

Most patients can be started on 1 to 2 mg of colchicine the first day and then maintained on 0.5 to 1.0 mg daily. As colchicine is partially cleared by renal excretion, patients with renal insufficiency should receive a reduced dosage.8 Although there is no clearly defined length of colchicine therapy, the COPE trial investigators treated patients for 3 months, which we would recommend as a minimum.

Resources

CoreEM

The first step in diagnosis of pericarditis should be to think about and eliminate STEMI as the diagnosis. STEMI ST elevations are convex...

StatPearls

In the majority of patients, empiric treatment with high dose anti-inflammatory agents in addition to colchicine is recommended, and NSAID therapy should continue until symptom relief. This period is typically between 3 days to 2 weeks.