GOOD MORNING!Thursday April 26th, 2012

Pericarditis• *Inflammatory condition that can arise from a wide variety of causes:• Infection• Autoimmune

• JIA, SLE

• Rheumatic fever• Uremia•Malignancy• Reaction to a drug• Post cardiac surgery• Idiopathic (30%)

*Viral infection Most common cause Prodrome of respiratory or GI illness

Coxackievirus Echovirus Adenovirus EBV Influenza HIV

Presentation = fever, chest pain, friction rub

Often accompanied by myocarditis

*Bacterial pericarditis Less common, but higher mortality

Staph aureus Haemophilus influenzae

Presentation = toxic appearance, high temp, irritable, chest pain, cardiomegaly

May be post-op or from another site (PNA) TB pericarditis

Spread from lymph nodes or blood borne Large effusions and cardiac tamponade common

Clinical Manifestations Chest pain tends to be substernal,

sharp, worse with inspiration and relieved by sitting upright and leaning forward Radiates to scapular ridge

Pericardial friction rub Scratchy, high-pitched to-and-fro sound Heard best in 2nd and 4th intercostal space at

LSB midclavicular line

*Lab Eval Elevated WBC, ESR, and CRP Troponin may be increased Blood cx, viral cx, TB skin testing,

gastric cultures for Mycobacterium, RF, and ANA may be helpful

ECG most useful diagnostic test

Question A 15-year-old patient is brought to your office with

the complaint of chest pain. She had been healthy until 3 days ago, when she developed a fever. The pain is percordial, referred to the epigastrum, and exacerbated by deep breathing and coughing. She refuses to lie down and prefers to sit leaning forward.

Of the following, the MOST likely expected finding on ECG is: A. elevation of S-T segment B. first-degree heart block C. pre-excitation with a delta wave D. tall peaked T waves E. T-wave flattening

ECG 4 stages

1. Diffuse ST segment elevation and PR segment depression

2. Normalization of the ST and PR segments

3. Development of widespread T-wave inversions

4. Normalization of the T-waves If effusion is present → low-

voltage QRS If cardiac tamponade →

electrical alternans

CXR Usually normal If effusion present,

then triangular shaped heart with smooth border

“Water-bottle” heart

Echo May be normal May reveal effusion

Absence of effusion does not exclude pericarditis

*Management Treat the underlying cause NSAIDS = to alleviate chest pain

If chest pain persists beyond 2 weeks, colchicine can be added

Steroids = reserved for those unresponsive to NSAIDS and colchicine or with a rheumatologic or recurrent disease

Pericardiocentesis = indicated with hemodynamic compromise, cardiac tamponade, purulent pericarditis, and suspected neoplastic pericarditis Resistant cases→ pericardial window or

pericardiectomy

Complications Recurrence (30%) Constrictive pericarditis Cardiac tamponade

Bleeding DisordersDr. GardnerNoon Conference with Lunch