QuestionSBA
QuestionChoice
Nebulised bronchodilators would be indicated in asthma. There are no features to suggest asthma such as shortness of breath, wheeze or a prior history of atopy
32255
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Nebulised bronchodilators
QuestionChoice
The most likely diagnosis is acute pericarditis. This is inflammation of the pericardium that typically lasts for less than 4-6 weeks and is characterised by central chest pain relieved by sitting forward. The pain is also pleuritic, meaning that it is worse on inspiration. As described in this case, a prodromal viral illness may be associated with pericarditis as a viral infection is a common precipitant.

The most specific sign on ECG for acute pericarditis is PR depression. This can also be associated with widespread, concave ST elevation.

The first-line management of pericarditis is with a short course of a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen
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Non-steroidal anti-inflammatory drug (NSAID)
QuestionChoice
LMWH would be used for the treatment of a pulmonary embolus (PE). A PE is an important differential to consider in this case as it can present with pleuritic chest pain. However, pain relieved by sitting forward and a history of a recent viral illness favour a diagnosis of pericarditis more
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Low molecular weight heparin (LMWH)
QuestionChoice
Pleuritic chest pain can be a sign of pneumonia for which antibiotics would be indicated. However, the ECG findings in combination with the prodrome of coryzal prodrome is suggestive of acute pericarditis
32254
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Oral antibiotics
QuestionChoice
Aspirin would be indicated in acute coronary syndrome (ACS). This patient's pain does not have any ischaemic characteristics and is pleuritic in nature. He also does not have any risk factors for ischaemic heart disease
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Aspirin 300mg
Concept
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# Summary

Acute pericarditis is the inflammation of the pericardium, the sac surrounding the heart. It is commonly seen in patients with chest pain following a viral infection, with pain typically relieved by leaning forward. The condition can be caused by various factors including infections (viral, bacterial), malignancies, cardiac causes, radiation, drugs/toxins, and rheumatological diseases. Diagnosis is based on clinical evaluation, ECG findings (ST elevation, PR depression), and imaging such as echocardiogram. Treatment options include NSAIDs, colchicine, and corticosteroids depending on the underlying cause. Complications are rare, and the prognosis is generally excellent with a low risk of long-term sequelae.  

# Definition 

Acute pericarditis is inflammation of the pericardium, the fibroelastic sac that surrounds the heart. Inflammation can also extend to the myocardium (heart muscle), in which case the condition is referred to as perimyocarditis or myopericarditis depending on which is predominant. 

# Epidemiology 

Acute pericarditis is one of the most common causes of pericardial disease and is estimated to occur in approximately 27.7 per 100,000 people annually. 

# Pathophysiology

The pathophysiology of pericarditis depends on the cause. The causes of pericarditis are discussed below. 

# Causes

The classification of pericarditis can be considered according to cause of the pericarditis. 

* Idiopathic

* Infective causes

  * Viruses - viruses which cause pericarditis are **coxsackie B viruses**, echovirus, CMV, herpesvirus, HIV among other rarer causes.
  * Bacteria - staphylococcus, pneumococcus, streptococcus (rheumatic carditis), haemophilus and M. tuberculosis.
  * Fungi and parasites (rare)

* Malignant causes

  * Lung cancer
  * Breast cancer
  * Hodgkin's lymphoma

* Cardiac causes

  * Heart failure may cause pericarditis
  * Post-cardiac injury syndrome (Dressler's syndrome) including post-traumatic

* Radiation - often secondary to therapy for other malignancies

* Drugs and toxin causes

  * Anthracycline chemotherapy (Doxorubicin)
  * Hydralazine
  * Isoniazid
  * Methyldopa
  * Phenytoin
  * Penicillins (hypersensitivity)

* Rheumatological disease

  * Systemic lupus erythematous (SLE)
  * Rheumatoid arthritis
  * Sarcoidosis
  * Vasculitides (Takayasu's, Behcet's)

* Other causes
  * Renal failure (uraemia) - indication for emergency dialysis. 
  * Hypothyroidism
  * Inflammatory bowel disease
  * Ovarian hyperstimulation
  
# Symptoms

* Pleuritic chest pain: central, worse on inspiration. 
* Postural chest pain: worse on lying flat and relieved on leaning forward.
* Fever

# Signs

* Pericardial friction rub - high-pitched scratching noise, best heard over the left sternal border during expiration. Pathogonomonic of pericarditis. 
* Pericarditis can lead to the development of a pericardial effusion and cardiac tamponade in which case signs such as hypotension, raised JVP and muffled heart sounds (Beck's Triad) may be present. 

# Differential Diagnoses 

* **Acute Coronary Syndrome** 
	* **Similarities**: both present with chest pain. 
	* **Differences**: pericarditic chest pain is often described as sharp, pleuritic in nature, and relieved on sitting forward. In ACS, the chest pain is often described as a squeezing pressure that is not positional. 


* **Pleuritic Chest Pain e.g. Pulmonary Embolism or Pneumonia** 
	* **Similarities**: both present with pleuritic chest pain. 
	* **Differences**: PE and pneumonia will often present with very different histories and clinical features. Patients with pneumonia will describe a productive cough and fevers, whereas patients who have a pulmonary embolism will describe acute-onset pleuritic chest pain and will likely have risk factors for VTE. 

* **Musculoskeletal Chest Pain** 
	* **Similarities**: various MSK conditions including costochondritis or muscle strains can cause chest pain that resembles pericarditis. These pains may also be positional. 
	* **Differences**: MSK pain is reproducible with palpation or certain movements. 


* **Gastro-oesophageal Reflux Disease (GORD)** 
	* **Similarities**: chest pain seen in GORD may be similar to that seen in pericarditis. Those with GORD may describe that symptoms are worse on lying flat, similar to pericarditis. 
	* **Differences**: pericarditic pain is often described as sharp, whereas GORD discomfort may be described as a burning sensation that is worse with certain foods and bending over. 


# Investigations

The diagnosis of pericarditis is often clinical, but the following investigations can help aid diagnosis. 

## Bedside

**1st line** = ECG 

ECG features include: 

* Widespread saddle ST elevation (not following vascular territories) and PR depression. 

ECG changes can sometimes evolve over weeks:

* 1-3 weeks: normalisation of ST changes, T wave flattening
* 3-8 weeks: flattened T waves become inverted
* 8+ weeks: ECG returns to normal

[lightgallery]

## Bloods 

* Serial troponins: tend not to peak as in an MI, but tend to stay consistently elevated in the acute phase. 
* Inflammatory markers: raised inflammatory markers (WCC, CRP and ESR) are in keeping with an acute pericarditis. 
* Viral serology: may help to identify cause of the acute pericarditis. 

## Imaging

* Echocardiogram - used to assess for pericardial effusion and distinguish between pericarditis and MI (e.g. looking for the absence of regional wall motion abnormalities). 
* Angiogram - shows normal coronary arteries (which excludes MI).
* Cardiac MRI - in atypical cases, cardiac MRI can be used to visualise inflammation of the pericardium. 

# Management

## Idiopathic or Viral Pericarditis 

**1st line**: exercise restriction, NSAIDS (+ PPI) for 1-2 weeks and colchicine for 3 months

**2nd line**: colchicine (SE: diarrhoea, use in caution in those with renal or hepatic impairment). 

**3rd line**: corticosteroids (for those who cannot tolerate or refractory to NSAIDS). 

## Bacterial Pericarditis 

**1st line**: IV antibiotics +/- pericardiocentesis if purulent exudate present. 

Rare cases - pericardectomy may be performed if adhesions or recurrent tamponade occurs. 

## Non-Infective Pericarditis 

**1st line**: corticosteroids (due to the risk of reactivation and if infection has been ruled out). 

# Complications

Complications are rare but include cardiac tamponade and pericardial effusion requiring pericardiocentesis. In the long term patients occasionally develop constrictive pericarditis.

# Prognosis 

Acute pericarditis has an excellent prognosis with less than 0.5% going on to develop long-term sequelae (e.g. constrictive pericarditis). 

# NICE Guidelines

[NICE Guidelines on Cardiac Causes of Chest Pain](<https://cks.nice.org.uk/topics/chest-pain/diagnosis/cardiac-causes/>)

# References

[UptoDate Article on Acute Pericarditis: Treatment and Prognosis](<https://www.uptodate.com/contents/acute-pericarditis-treatment-and-prognosis>)
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Widespread ST segment changes in someone with pericarditis.
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Acute pericarditis presents with pleuritic chest pain, often relieved by sitting forward, and is initially managed with NSAIDs.
A 32-year-old man presents to his General Practitioner (GP) with a 3-day history of sharp, constant central chest pain. He reports the pain to be worse on inspiration and relieved by sitting forward. On questioning, he reveals a 1-week history of coryzal symptoms and myalgia, which are now improving. He denies cough, shortness of breath or palpitations.

He has no significant past medical history and examination and all observations are unremarkable.

An ECG shows widespread PR depression and concave ST elevation.

Given the likely diagnosis, which of the following is the first-line management?
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