Pericarditis 

Introduction

Pericarditis is an inflammation of pericardium, which can be an isolated disease or the first manifestation of underlying systemic disease.

Causes can be classified to infectious and non infectious. 

Infectious – mainly viral (enteroviruses, adenoviruses, Parvovirus B19, etc.); occasionally bacterial, fungal, TB

Non infectious - autoimmune, paraneoplastic syndrome, uraemia, Dressler’s syndrome, trauma, drug-induced

Clinical manifestation

The diagnosis is clinical and can be made based on following signs and symptoms:

  • pericardial (sharp central) chest pain - pleuritic, worse in the supine position or upon inspiration
  • pericardial friction rub upon auscultation 
  • pericardial effusion (new or worsening)
  • low-grade intermittent fever
  • dyspnoea, cough, malaise, myalgia 

ECG manifestation 

  • Stage 1 – diffuse concave ST elevation and PR depression in all leads (reciprocal ST depression and PR elevation in aVR)
  • Stage 2 – normalisation of ST changes; generalised T wave flattening (1 to 3 weeks)
  • Stage 3 – flattened T waves become inverted (3 to several weeks)
  • Stage 4 – ECG returns to normal or persistence of T-wave inversions (several weeks onwards)


Sinus tachycardia is also common in acute pericarditis due to pain and/or pericardial effusion.

Spodick’s sign

Downsloping TP segment seen as an early ECG manifestation in ~80% of patients with pericarditis, best visualised in leads II and the lateral precordial leads. 

Pericarditis vs. STEMI

  1. STE in pericarditis are concave; in AMI - convex or horizontal
  2. STE in pericarditis - diffuse; in AMI - localised
  3. Pericarditis - PR depression; AMI - Q waves
  4. Pericarditis - inversion of T waves appear after normalising of ST segment; AMI - T wave inversion appears with STE 

Treatment

First line therapy

  • aspirin (500–1000 mg every 6–8 hours; range 1,5–4 g/day
  • ibuprofen (600 mg every 8 hours; range 1200–2400 mg)
  • Indomethacin (25–50 mg every 8 hours)
  • colchicine (0.5 mg twice or 0.5 mg daily for patients
  • exercise restriction

Second line therapy (in case of contraindications to aspirin/NSAID/colchicine and after exclusion of infectious cause)

  • corticosteroids at low to moderate doses (i.e. prednisone 0.2–0.5 mg/kg/day)

I.v. immunoglobulin or anakinra or azathioprine in a recurrent pericarditis as a third line therapy.

Pericardiectomy in a recurrent pericarditis as a fourth line therapy.

ECG 1 Pericarditis (ST elevations I, II, aVL, aVF, V4-V6 + PR depression mainly seen in I, II, aVF)

ECG 2 Pericarditis -  widespread ST elevations

References

  1. Masek, Kevin P, and Joel T Levis. “ECG diagnosis: acute pericarditis.” The Permanente journal vol. 17,4 (2013): e146. doi:10.7812/TPP/13-044
  2. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristic AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W; ESC Scientific Document Group. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-2964. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29. PMID: 26320112; PMCID: PMC7539677.
  3. Diagnosis of acute pericarditis. European Society of Cardiology [online]. Copyright © 2021 European Society of Cardiology. All rights reserved. [cit. 05.02.2021]. Dostupné z: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Diagnosis-of-acute-pericarditis
  4. Marinella MA. Electrocardiographic manifestations and differential diagnosis of acute pericarditis. Am Fam Physician. 1998 Feb 15;57(4):699-704. PMID: 9490993.
  5. https://litfl.com/spodick-sign/