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KEY POINTS

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  • The diagnosis of acute pericarditis should be made on the basis of typical chest pain symptoms, the presence of a pericardial friction rub, and electrocardiographic abnormalities, which are distinctive from changes due to myocardial ischemia.

  • Although a comprehensive evaluation is usually warranted in patients with acute pericarditis, the diagnostic yield is low with causes identified in less than 20% of patients.

  • High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and adjunctive colchicine are effective medical therapy for acute pericarditis, except in episodes due to acute coronary syndromes where NSAIDs are contraindicated.

  • Pulsus paradoxus is a bedside finding of cardiac tamponade that arises from compromise in left ventricular stroke volume during inspiration and a subsequent fall in stroke volume.

  • Echocardiography is the primary diagnostic modality for tamponade. Signs include diastolic inversion or collapse of the right atrium and right ventricle, ventricular septal shifting with respiration, enlargement of the inferior vena, and respiratory variation in transmitral flow.

  • In patients in whom invasive monitoring is available (eg, Swan-Ganz catheter) cardiac tamponade manifests as blunting or absence of the y descent, elevation in filling pressures, tachycardia, and reduced cardiac output.

  • The diagnosis of constrictive pericarditis can be made with echocardiography in most patients, with invasive catheterization reserved for patients in whom the clinical findings and noninvasive studies cannot definitively establish the diagnosis.

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In the vast majority of patients with constrictive pericarditis, cardiac surgery with pericardiectomy is the definitive treatment for relief of heart failure.

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The pericardium is a fibroelastic sac comprised of parietal and visceral layers that normally contain 15 to 50 mL of plasma ultrafiltrate. Pericardial disorders can be broadly categorized into the clinical entities of acute pericarditis (with or without effusion), cardiac tamponade, and constrictive pericarditis.

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ACUTE PERICARDITIS

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Acute pericarditis may occur in isolation or as part of a systemic disorder. Although there are a variety of etiologies, the majority of cases are idiopathic or presumed to be viral or autoimmune in origin. In developing countries and susceptible individuals, tuberculosis and human immunodeficiency virus are common causes of acute pericarditis.

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DIAGNOSIS
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The diagnosis of acute pericarditis is made on the basis of typical chest pain symptoms, the presence of a pericardial friction rub, distinctive electrocardiographic abnormalities, and supportive data from noninvasive testing. The clinical presentation is characterized by chest pain in 90% to 95% of cases, with additional symptoms attributable to the underlying etiology. Chest pain due to acute pericarditis is typically anterior and sharp, with aggravation related to maneuvers that increase pericardial pressure (eg, cough, inspiration, orthostasis). These characteristics may be useful in distinguishing pericarditis from acute myocardial ischemia, but these features also are frequently present in other chest pain syndromes, such as pulmonary embolism, aortic dissection, costochondritis, and gastroesophageal reflux.

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A pericardial friction rub is the hallmark physical sign of pericarditis, and may be present in patients with or without a ...

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