The pericardium is a fluid-filled doubled-walled membrane sac that surrounds the heart. The fluid is separated by two layers, the fibrous and serous pericardium. The fibrous pericardium is the outer layer and holds the heart in place and protect it from surrounding infections. It is composed of thick connective tissue. The serous pericardium has two layers, the visceral and parietal layers. The visceral pericardium helps to minimize friction, and the parietal pericardium provides additional defense.
Injury to the pericardium leads to the release of inflammatory cells, fibrin, and fluid. Most commonly, acute pericarditis is idiopathic, and in 90% of the cases, an etiology remains undetermined. The remaining 10% are secondary to bacterial and viral infections, autoimmune disease, uremia, myocardial infarction, cardiac surgery, malignancy, trauma and, radiation.
The incidence and prevalence of acute pericarditis are unknown, and many cases are considered to go undiagnosed. One study showed that acute pericarditis might account for up to 5% of presentation to the emergency department and account for 0.1% of admissions for chest pain. Typically, the demographic affected are men aged between 20 to 50 years old.
Inflammation of the pericardium produces a serous or purulent discharge. For example, in viral pericarditis, the fluid is serous. Purulent discharge can present in neoplastic or tuberculous associated episodes of pericarditis.
Pericardial effusion may impede diastolic filling of the right heart if it accumulates too quickly and it may also result in constriction of the heart if the accumulation is persistent. This fluid accumulation may result in pericardial tamponade.
The pericardium is a fibro-serous membrane that covers the heart. The fibrous pericardium is composed of connective tissue cells, microvasculature, collagen fibers and, small elastic fibers. The serosal layer is composed of a surface layer of flattened mesothelial cells. The luminal surface of the serosal layer is lined with surface microvilli and few cilia to help increase the area for fluid transport.
Acute retrosternal chest pain that is sharp and pleuritic presents in over 95% of cases of acute pericarditis. The chest pain is classically pleuritic and worsened by coughing, breathing and sitting up-right. Chest pain is often relieved by leaning forward. 
The most important physical sign in pericarditis is the pericardial friction rub. The friction rub is best heard while the patient is upright and leaning forward. It is a high pitched, scratching sound heard at the left lower sternal border during expiration. The pericardial friction rub has three distinct components that correspond to the cardiac cycle. These components are heard during atrial systole, ventricular systole and rapid ventricular filling during early diastole.
Other critical clinical signs to be aware of are signs of tamponade such as raised jugular venous pressure (JVP), muffled heart sounds and decreased blood pressure. If pericardial tamponade is concerned, a pulsus paradoxus is recommended.
Dianosis requires two of the following criteria. Pericardial friction rub; the characteristic sharp and pleuritic chest pain; electrocardiography changes; and a new or worsening pericardial effusion. Additionally, electrocardiography, chest radiography and laboratory studies should support the diagnosis. The white blood cell count, erythrocyte sedimentation rate, and serum CRP level usually are elevated. Electrocardiographic changes occur in stages. Stage I shows diffuse, concave ST-segment elevation. Stage II shows ST segment normalization, J point return to baseline, T wave amplitude begins to decrease, PR-segment depression begins to appear. Stage III is symmetric, diffuse T-wave inversions. Stage IV occurs when the T-wave inversions normalize or become permanent.
The therapy for acute pericarditis should be targeted as much as possible to the underlying etiology. There are no randomized controlled trials, but pericarditis is usually treated empirically. One study showed nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine worked well for patients with presumed viral or idiopathic pericarditis. It was recommended the therapy be continued for two weeks or until symptoms resolve.
Glucocorticoids should be used for initial treatment of acute pericarditis only in patients with contraindications to NSAIDs or for specific indications such as systemic inflammatory diseases.
Pericardiocentesis is the management of choice for cardiac tamponade. If it re-occurs a pericardial window can be performed. In constrictive pericarditis, the treatment of choice is pericardiectomy.
It is not necessary to hospitalize patients with acute pericarditis unless they have high-risk features such as leukocytosis, large pericardial effusion, tamponade physiology, and an immunocompromised state.
Pericarditis may be confused with myocardial infarction, esophageal disorders or other non-cardiac chest pain. It is therefore essential to use the diagnostic criteria and rule out other life-threatening causes of chest pain.
Three potential complications may occur from pericarditis. These complications arise from the compression of the heart. Cardiac tamponade occurs when the pericardial pressure is high enough to impede filling of the right heart. Constrictive pericarditis occurs when scarring and loss of the elasticity lead to impairment of diastolic filling and effusive-constrictive pericarditis occurs when there is constrictive physiology with a coexisting pericardial effusion resulting in a mixed hemodynamic picture.
Patients with chest pain that is suggestive of pericarditis should seek immediate medical care. Pericarditis can become a life-threatening condition and may lead to compression of the heart. Acute pericarditis usually cannot be prevented, but it is treatable. Symptoms of fainting and rapid breathing are signs that your pericarditis may be progressing.
Expert opinion is primarily used to treat pericarditis. NSAIDs and colchicine are considered effective treatment options. Currently recommended doses are aspirin 650 mg every 4 to 6 hours, ibuprofen 400 mg every 4 to 6 hours or acetaminophen 500 mg every 4 to 6 hours. One study named the Colchicine for Acute Pericarditis Trial (COPE), showed colchicine to be the first-line adjuvant drug for the treatment and prevention of pericarditis (Level of Evidence A). Colchicine is thus recommended for patients with their index event of pericarditis. Patients with renal insufficiency, motility disorders or bleeding disorders should avoid or be cautious with the use of colchicine. Currently recommended doses for colchicine are 2 to 3 mg per day for at least 6 months to 1 year.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
|Roberts WC, Pericardial heart disease: its morphologic features and its causes. Proceedings (Baylor University. Medical Center). 2005 Jan; [PubMed]|
|Snyder MJ,Bepko J,White M, Acute pericarditis: diagnosis and management. American family physician. 2014 Apr 1; [PubMed]|
|Khandaker MH,Espinosa RE,Nishimura RA,Sinak LJ,Hayes SN,Melduni RM,Oh JK, Pericardial disease: diagnosis and management. Mayo Clinic proceedings. 2010 Jun; [PubMed]|
|Sheth S,Wang DD,Kasapis C, Current and emerging strategies for the treatment of acute pericarditis: a systematic review. Journal of inflammation research. 2010; [PubMed]|
|Imazio M,Bobbio M,Cecchi E,Demarie D,Demichelis B,Pomari F,Moratti M,Gaschino G,Giammaria M,Ghisio A,Belli R,Trinchero R, Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005 Sep 27; [PubMed]|
|Permanyer-Miralda G, Acute pericardial disease: approach to the aetiologic diagnosis. Heart (British Cardiac Society). 2004 Mar [PubMed]|
|Spodick DH, Acute pericarditis: current concepts and practice. JAMA. 2003 Mar 5 [PubMed]|
|Ishihara T,Ferrans VJ,Jones M,Boyce SW,Kawanami O,Roberts WC, Histologic and ultrastructural features of normal human parietal pericardium. The American journal of cardiology. 1980 Nov [PubMed]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Rheumatology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Rheumatology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Rheumatology, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Rheumatology. When it is time for the Rheumatology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Rheumatology.