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[pericard(ium) + -itis]
Inflammation of the pericardium, marked by chest pain, fever, and an audible friction rub.
SEE: Dressler syndrome
The precise incidence of pericarditis is unknown. Among patients presenting in ERs with chest pain, approx. 5% have pericarditis rather than coronary artery disease, pulmonary embolism, esophageal gastric or biliary disease or other more common causes. Approx. 1 patient per 1000 admitted to hospital is diagnosed with pericarditis. Infectious causes of pericarditis are more common in patients with HIV/AIDS than in other patient populations.
Many diseases and conditions can inflame the pericardium, including infections (bacterial, tubercular, viral, fungal); collagen-vascular diseases (such as rheumatic fever, rheumatoid arthritis, or systemic lupus erythematosus); drugs (hydralazine, procainamide, isoniazid, minoxidil); myocardial infarction; cancer; renal failure; cardiac surgery; or trauma. In many instances the precise cause is idiopathic (unknown).
SYMPTOMS AND SIGNS
Chest pain that varies with respiration is a hallmark of pericarditis. The pain often worsens when the patient lies down and improves when he or she sits up and leans forward. The pain is usually described as sharp, constant, and located in the mid chest (retrosternally), but it may radiate to the neck, shoulder, and back. Fever, cough, dyspnea, and palpitations are also characteristic. The classic sign of pericarditis is the pericardial rub (found in about 50% of cases), a multicomponent abnormal heart sound that some observers describe as high-pitched, scratchy, raspy, grating, or leathery. It is best heard with the diaphragm of the stethoscope at the left lower sternal border as the patient sits up, leans forward, and holds his or her breath after expiration.
Diagnosis is usually based on the clinical presentation, electrocardiogram changes, and echocardiography. Pericardiocentesis is used to obtain fluid for analysis in selected patients, e.g. those with high fevers, cardiac tamponade, or evidence of systemic illness. Fluid obtained by pericardiocentesis should be sent for microbiological studies such as tests for Mycobacterium tuberculosis (MTB), fungí, and cytology.
Therapy depends on the cause of the syndrome. Uremic pericarditis is treated with dialysis; pyogenic pericarditis requires antibiotic therapy and drainage. Nonsteroidal anti-inflammatory drugs and colchicine improve outcomes in patients with idiopathic disease. Many cases of pericarditis are self-limiting, but without treatment others may progress to chronic constrictive pericarditis or cardiac tamponade.
IMPACT ON HEALTH
Left untreated, idiopathic pericarditis improves on its own, but about a quarter of patients experience recurrent disease. Some secondary forms of pericardial inflammation, such as tuberculous pericarditis, or pericarditis caused by cancer, prove lethal.
The patient is observed closely for symptoms of cardiac tamponade, such as pallor and clammy skin, pulsus paradoxus (systolic blood pressure at least 10 mm Hg lower during slow inspiration than during expiration), weak or absent peripheral pulses, distended neck veins, decreased blood pressure, and narrowing pulse pressure. Patients with chronic constrictive pericarditis usually require a total pericardectomy to permit adequate filling and contraction of the heart. If surgery is required, the patient is taught deep-breathing and coughing (incentive spirometry) exercises beforehand as time permits. Postoperative care is as for other cardiothoracic surgical patients. Medications are administered as prescribed. Activities are restricted; vigorous exercise should be avoided until pain and fever subside, which may take weeks to months. In the convalescent phase, the patient is taught about the importance of taking prescribed medications, their purposes, and any potentially recurring symptoms to report. The patient is encouraged to keep all scheduled follow-up appointments and to notify the primary health care provider immediately if changes in symptoms occur, such as return or worsening of pain, difficulty with breathing, irregular heart beats, or loss of consciousness.