| Snapshot |
| A 58-year-old woman with a past medical history of systemic lupus erythematosus presents to the emergency room for sharp chest pain. She reports that it is worse with inspiration and gets better when she leans forward. On physical exam, there is a friction rub that is loudest when she leans forward. An electrocardiogram shows widespread ST elevation. |
| Introduction |
| Clinical definitioninflammation of the pericardium characterized by sharp pain worsened by inhalationEtiologyserousautoimmune diseasesystemic lupus erythematosus rheumatoid arthritisuremiaviral illnesscoxsackievirusfibrinous pericarditiscomplication of myocardial infarction (MI) 1-3 days after and several weeks after (Dressler syndrome) the MIsystemic lupus erythematosusuremiarheumatic feverhemorrhagic tuberculosismalignancyconstrictiveradiation therapyviral illnesstuberculosisPathogenesisinflammation of the pericardium can cause chest painmovement of the heart can cause friction between the 2 pericardial layers, producing a friction rubinflammation may cause a pericardial effusionPrognosiscan be acute or chronic, and may recurviral pericarditis is usually self-limited |
| Presentation |
| Symptomssharp pleuritic chest pain that is worsened by inhalation pain is also relieved by sitting up and leaning forward shoulder pain (referred pain) pericarditis is innervated by phrenic nervePhysical exammay have a feverfriction rubpathognomonicKussmaul sign seen in constrictive pericarditis↑ jugular venous distention on inspiration |
| Imaging |
| Echocardiography indicationto assess for pericardial effusion and cardiac tamponadeRadiography indicationto rule out pneumonia or other pulmonary pathologyfindingsconstrictive pericarditis may have pericardial calcifications on radiography |
| Studies |
| Labs↑ erythrocyte sedimentation rate↑ C-reactive proteinmay have ↑ troponin IElectrocardiogram (ECG) PR segment depression in most leads except aVR where the reflections are opposite of all other leadslead II may show the most pronounced depressions leep<a target=”_blank” href=”https://www.medbullets.com/step1-stats/1030/sleep” rel=”nofollow”>www.medbullets.com/step1-stats/1030/sleep</a>widespread ST segment elevations upright T wavesweeks after pericarditis, this will become inverted T wavesclassic ECG signs may be absent in uremic pericarditisMaking the diagnosisbased on clinical presentation and ECG findings |
| Differential |
| Cardiac tamponade distinguishing factorpulsus paradoxus and Beck triad on examMyocardial infarctiondistinguishing factormore focal ST elevation on ECG suggestive of anatomic damage |
| Treatment |
| Conservativerestriction of exerciseindicationfor all patientsMedicalnonsteroidal anti-inflammatory drugs (NSAIDs)indicationbest initial therapydrugsindomethacinnaproxenibuprofenaspirinprednisoneindicationpain refractory to NSAIDscolchicineindicationadjunct therapy to NSAIDs or steroidsNon-operativepericardiocentesisindicationin patients with pericardial effusion or cardiac tamponadedialysisindicationfor patients with pericarditis from uremia |
| Complications |
| Pericardial effusion and tamponade |
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