Acute Pericarditis: Diagnosis and Management



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Am Fam Physician. 2014 Apr 1;89(7):553-560.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on acute pericarditis written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Acute pericarditis, inflammation of the pericardium, is found in approximately 5% of patients admitted to the emergency department for chest pain unrelated to acute myocardial infarction. It occurs most often in men 20 to 50 years of age. Acute pericarditis has a number of potential etiologies including infection, acute myocardial infarction, medication use, trauma to the thoracic cavity, and systemic diseases, such as rheumatoid arthritis. However, most etiologic evaluations are inconclusive. Patients with acute pericarditis commonly present with acute, sharp, retrosternal chest pain that is relieved by sitting or leaning forward. A pericardial friction rub is found in up to 85% of patients. Classic electrocardiographic changes include widespread concave upward ST-segment elevation without reciprocal T-wave inversions or Q waves. First-line treatment includes nonsteroidal anti-inflammatory drugs and colchicine. Glucocorticoids are traditionally reserved for severe or refractory cases, or in cases when the cause of pericarditis is likely connective tissue disease, autoreactivity, or uremia. Cardiology consultation is recommended for patients with severe disease, those with pericarditis refractory to empiric treatment, and those with unclear etiologies.

Acute pericarditis is the most common affliction of the pericardium. It is diagnosed in approximately 0.1% of patients hospitalized for chest pain and in 5% of patients admitted to the emergency department for chest pain unrelated to acute myocardial infarction (MI).1 Although acute pericarditis occurs in all age groups and in men and women, it presents most often in men 20 to 50 years of age.2 Acute pericarditis by itself confers low mortality; however, the high rate of recurrence and the difficulty of controlling symptoms contribute to high morbidity. After an initial episode of acute pericarditis, 30% of patients have a recurrence.3  Factors associated with increased morbidity are shown in Table 1.46

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Evaluation of patients with acute pericarditis should include a history, physical examination, electrocardiography, chest radiography, and baseline laboratory studies (i.e., complete blood count, basic metabolic panel, troponin-I and creatine kinase levels, erythrocyte sedimentation rate, and serum C-reactive protein levels). Additional laboratory testing and imaging are dictated by clinical presentation and risk factors.

C

2, 7, 15

Transthoracic echocardiography should be performed in all patients with suspected acute pericarditis to exclude pericardial effusion and cardiac tamponade.

C

19

Patients with acute pericarditis should be treated empirically with nonsteroidal anti-inflammatory drugs.

C

7

Colchicine may be used as monotherapy or in combination with a nonsteroidal anti-inflammatory drug for the first episode of acute pericarditis.

C

23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Evaluation of patients with acute pericarditis should include a history, physical examination, electrocardiography, chest radiography, and baseline laboratory studies (i.e., complete blood count, basic metabolic panel, troponin-I and creatine kinase levels, erythrocyte sedimentation rate, and serum C-reactive protein levels). Additional laboratory testing and imaging are dictated by clinical presentation and risk factors.

C

2, 7, 15

Transthoracic echocardiography should be performed in all patients with suspected acute pericarditis to exclude pericardial effusion and cardiac tamponade.

C

19

Patients with acute pericarditis should be treated empirically with nonsteroidal anti-inflammatory drugs.

C

7

Colchicine may be used as monotherapy or in combination with a nonsteroidal anti-inflammatory drug for the first episode of acute pericarditis.

C

23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Predictors of Severe Illness in Patients with Acute Pericarditis

Major

Fever > 100.4°F (38°C)

Subacute onset

Evidence suggestive of cardiac tamponade

Large pericardial effusion (an echo-free space greater than 20 mm)

Nonsteroidal anti-inflammatory drug therapy ineffective after seven days

Minor

Immunosuppressed state

History of oral anticoagulant therapy

The Authors

MATTHEW J. SNYDER, DO, is the assistant program director and director of obstetrics at the Nellis Family Medicine Residency Program at Nellis Air Force Base, Nev.

JENNIFER BEPKO, MD, is director of geriatrics for the David Grant Medical Center Family Medicine Residency Program at Travis Air Force Base, Calif. At the time the manuscript was written, Dr. Bepko was director of geriatrics at the Nellis Family Medicine Residency Program.

MERIMA WHITE, DO, is a third-year resident at the Nellis Family Medicine Residency Program.

Address correspondence to Matthew J. Snyder, DO, Nellis Family Medicine Residency, 4700 N. Las Vegas Blvd., Nellis AFB, NV 89191 (e-mail: mdrnsnyder@gmail.com). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

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