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KembaraXtra -Medicine- Emergency and Acute Medicine – Pericarditis
Pericarditis is inflammation, infection, or infiltration of the pericardial sac surrounding the heart. A pericardial effusion may or may not be present. Acute pericarditis has a rapid onset and may be complicated by cardiac tamponade if significant fluid accumulates. Constrictive pericarditis results from chronic inflammation leading to thickening, fibrosis, and adherence of the pericardium to the myocardium, impairing diastolic filling.
The most common cause is idiopathic, presumed viral in many cases. Viral etiologies include coxsackievirus, echovirus, adenovirus, Epstein–Barr virus, cytomegalovirus, hepatitis B, HIV, and others. Bacterial causes include tuberculosis, staphylococcal and streptococcal species, Haemophilus, Salmonella, and Legionella. Fungal, parasitic, neoplastic, uremic, autoimmune, post–myocardial infarction (Dressler syndrome), radiation, trauma, postpericardiotomy, aortic dissection, myxedema, pancreatitis, inflammatory bowel disease, amyloidosis, and drug-induced causes are also recognized.
Chest pain is the hallmark symptom. It is typically sharp, pleuritic, and substernal, worsened by lying supine or coughing, and improved by sitting up or leaning forward. Pain may radiate to the trapezius ridge due to phrenic nerve irritation. Associated symptoms include fever, mild dyspnea, cough, hoarseness, nausea, and anorexia. A history of recent viral illness, autoimmune disease, malignancy, or prior pericarditis episodes is common.
On examination, tachycardia and tachypnea may be present. A pericardial friction rub is highly specific and best heard at the lower left sternal border, often accentuated when the patient leans forward. The classic rub is triphasic, with presystolic, systolic, and early diastolic components, though any combination may be heard. If a significant effusion develops, features of cardiac tamponade may appear, including hypotension, jugular venous distention, and muffled heart sounds. Pulsus paradoxus may be present. Constrictive pericarditis produces signs of right- and left-sided heart failure such as peripheral edema, ascites, hepatic congestion, and pulmonary edema.
Electrocardiography typically demonstrates four classic stages. Stage 1 shows diffuse concave ST elevation with PR depression, except in aVR and V1. Stage 2 reveals normalization of ST and PR segments with T-wave flattening. Stage 3 shows diffuse T-wave inversion. Stage 4 reflects normalization of T waves. Electrical alternans suggests a significant effusion. Cardiac enzymes may be mildly elevated in myopericarditis but are useful to distinguish from acute myocardial infarction.
Laboratory studies may show leukocytosis and elevated inflammatory markers such as ESR and C-reactive protein. Chest radiograph is usually normal unless more than 250 mL of fluid has accumulated, in which case cardiomegaly may be visible. Echocardiography is the diagnostic modality of choice for detecting pericardial effusion and can identify even small fluid collections. CT scanning can detect pericardial thickening or calcifications, particularly in constrictive pericarditis. Pericardiocentesis is reserved for diagnostic clarification or therapeutic relief in tamponade.
Initial management follows standard airway, breathing, and circulation principles. Emergent pericardiocentesis is indicated in hemodynamically unstable patients with tamponade. Most cases of idiopathic or viral pericarditis are treated with nonsteroidal anti-inflammatory drugs. Ibuprofen or aspirin are commonly used and may be tapered gradually to reduce recurrence. Colchicine is recommended in combination with NSAIDs to decrease recurrence rates and may be continued for approximately three months. Corticosteroids are reserved for refractory cases, autoimmune causes, or when NSAIDs are contraindicated, as they are associated with higher recurrence rates. Bacterial pericarditis requires urgent IV antibiotics and drainage. Uremic pericarditis requires intensified dialysis. Neoplastic pericarditis is managed in conjunction with oncology.
Patients with hemodynamic instability, cardiac tamponade, malignant arrhythmias, large effusions, anticoagulation use, high fever, immunosuppression, trauma, malignancy, or suspected bacterial etiology require hospital admission, often to a monitored or intensive care setting. Stable patients with mild symptoms and no high-risk features may be managed as outpatients with close follow-up.
The classic presentation includes a recent viral illness followed by sharp, positional chest pain and a friction rub. Distinguishing pericarditis from acute myocardial infarction and other causes of chest pain is critical. NSAIDs remain the cornerstone of therapy, and most patients improve within two weeks with appropriate treatment.
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