Pericarditis

Question 1

List 8 indications for inpatient mgt of pericarditis.

Answer 1

• Fever >38deg
• Sub-acute course (no abrupt onset of pain)
• Evidence of tamponade (haemodynamic compromise)
• Large pericardial effusion - end-diastolic echo-free space >20mm
• Immunosuppression/compromised patients
• Concurrent anticoagulation
• Acute trauma
• Failure to improve w/ 7days NSAID + colchicine therapy
• Elevated cTnI -> suggests perimyocarditis or myopericarditis

Question 2

List the aims of treatment in pericarditis.

Answer 2

• Analgesia
• Reduction of inflammation and/or effusion
• Avoidance of strenuous activity -> may precipitate recurrence
• Prevention of recurrence

Question 3

What are the complications of pericarditis?

Answer 3

• Cardiac tamponade
• Constrictive pericarditis

Question 4

Outline the pharmaceutical treatment of pericarditis.

Answer 4

If specific cause is known - treat the cause.

For idiopathic or viral:

• NSAIDs
  
  • Ibuprofen 800mg q8h until resolution of symptoms for 24hr then taper over 2-4wks to reduce recurrence rate
  • Aspirin 1000mg q8h until resolution of symptoms for 24hr then taper over 2-4wks to reduce recurrence rate

NB: if there is a risk of GI issues (hx PUD, age >65, concurrent aspirin, steroids or anticoagulation) add PPI protection

• Colchicine - good evidence to show efficacy of colchicine in addition to NSAID Rx
  
  • Wt >=70kg - 0.5mg bd (optional loading dose of 1mg bd on first day)
  • Wt < 70kg - 0.5mg od (optional loading dose of 0.5mg bd on first day)
  • Colchicine should be continued for 3mths

NB: side effects are rare at these low doses - GI (D+V), bone marrow suppressin, hepatotoxicity - beware toxicity in renal failure.

• Glucocorticoids - lowest possible dose and only in cases where there is contraindication to NSAIDs and/or other specific indications for steroids

Question 5

What are the common causes of pericarditis?

Answer 5

• Idiopathic - most common
• Infectious
  
  • Viral - coxsackievirue, echovirus, adenovirus
  • Bacterial - TB (most common in TB endemic regions, Staph, Strep, gonorrhoea, chlamydia
  • Fungal - Histoplasma, Aspergillus, Candida
  • Parasitic - Toxoplasmosis
• Non-infectious
  
  • ​Auto-immune - lupus, RA,
  • Neoplasm - Metastatic, primary, paraneoplastic
  • ​Cardiac - post MI (Dressler syndrome), myocarditis, dissecting aneurysm
  • Trauma - Blunt, penetrating, iatrogenic
  • Metabolic - hyperthyroidism, uraemia, ovarian hyperstim’n
  • Radiation
  • Drugs

Question 6

What is the recurrence rate of pericarditis?

Answer 6

15-40%

Question 7

List the common ECG changes in pericarditis.

Answer 7

• Widespread concave STE
• Widespread PR depression
• Reciprocal changes (ST Dep + PR elev in aVR +/- V1)
• Sinus tachycardia
• If large effusion or tamponade:
  
  • Electrical alternans
  • Low voltages

Question 8

What is the pattern of ECG changes over time in pericarditis?

Answer 8

1. ~2wks - STE +PR dep w/ reciprocal aVR changes
2. ~1-3wks - normalisation of ST changes and flattening of Twaves
3. >3wks - Flattened Twaves invert
4. >3wks - Normalisation of ECG

Question 9

What factors of suggest STE stemming from pericarditis rather than BER or AMI?

Answer 9

• Widespread in PC, territory in BER/AMI
• Only reciprocal change is in aVR in PC, elsewhere in AMI, nil in BER
• No dynamic change in PC or BER, may be dynamic in AMI
• ST concave in PC + BER, may be convex in AMI
• PR depression in PC - nil in BER/AMI
• No q-waves in PC, may be in AMI
• Fishook pattern or notched j-point in V4 suggest BER