Pericarditis

American Journal of Critical Care, Nov, 2006 by Laurie G. Futterman, Louis Lemberg

A 23-year-old ski lift attendant in Telluride, a skiing village in southern Colorado, was awakened one morning with chest pains that lessened when he sat up. The symptoms persisted and the young man decided to see an internist in Durango, Colo, a larger town several miles south of Telluride, because medical facilities in the village were limited to treatment of skiing injuries. On detailed questioning by the internist, the patient admitted to having had a mild "cold" the day before and that the chest pains were precordial with radiation to the area of the trapezia. On auscultation over the precordium with the stethoscopic diaphragm, which is preferred when auscultating high-frequency sounds, a biphasic or "to and fro" precordial friction rub was heard and was most apparent along the left mid to lower sternal edge. The electrocardiogram revealed the classic features of acute pericarditis (Figure 1). The patient was hospitalized for 48 hours to help ascertain the etiology.

[FIGURE 1 OMITTED]

QUESTIONS

1. Clinical signs and symptoms of acute pericarditis include which of the following?

a. midsternal pressure or pain that lessens when the patient sits and leans forward

b. midsternal pressure or pain that is enhanced when the patient sits

c. chest pains that are relieved by sublingual nitroglycerin

d. pericardial friction rubs, which are best heard with the bell of the stethoscope

2. What are the electrocardiographic features in acute pericarditis?

a. "J" point elevation in all leads

b. sinus tachycardia

c. "J" point elevation in all leads except a VR and frequently [V.sub.1]

d. atrial and ventricular premature beats

e. prolonged QT interval

3. What factors in acute pericarditis determine the level of risk?

a. gradual onset of symptoms

b. fever (body temperature >38[degrees]C)

c. failure to respond to nonsteroidal anti-inflammatory drugs (NSAIDs)

d. a large pericardial effusion or tamponade

e. traumatic pericarditis

f. any of the above

4. Pericardial disease can be difficult to diagnose because of which of the following?

a. pericardial disease may be silent

b. pericarditis complicating acute myocardial infarction (MI) is uncommon

c. steroid use in pericarditis complicating acute MI

5. The echocardiogram in acute pericarditis and tamponade is useful in which of these functions?

a. to quantify the size of a pericardial effusion

b. to determine the presence and location of a pericardial effusion

c. to document the hemodynamic impact of effusion on cardiac chambers

d. to provide follow-up surveillance for resolution or progression of an effusion

e. all of the above

6. A diagnostic pericardiocentesis is indicated in which of the following circumstances?

a. the history is noncontributory

b. to determine the infective agent in acute bacterial infection

c. to rule out malignant neoplasms

d. to rule out an opportunistic infection

e. after cardiac surgery

7. Treatment of acute viral or idiopathic pericarditis includes which of the following?

a. aspirin and NSAIDs

b. aspirin and steroids

c. colchicine and rest

d. steroids and rest

8. The disappearance of Dressler's syndrome (ie, acute pericarditis after MI) is attributed to which of the following?

a. the lower incidence of large transmural MIs

b. the early use of thrombolytics in acute MI

c. increased use of antibiotics in the general population

d. drug-eluting coronary stents

ANSWERS

1. a. midsternal pressure or pain that lessens when the patient sits and leans forward

The pain in acute pericarditis is centralized and radiates to the trapezial or scapular areas as a consequence of phrenic nerve irritation. (1-3) The pain is accentuated with inspiration and in recumbency, and it is promptly lessened or relieved by sitting and leaning forward. Anginal pain is also lessened in the sitting position, but requires a few moments to improve in contrast to the immediate relief seen when the chest pain is due to acute pericarditis. The improvement in anginal pain when changing from recumbency to a sitting position occurs after a brief time that allows a reduction in blood volume return to the heart as a consequence of gravitational forces. The salutary effect is a decrease in cardiac work.

A high-frequency vibratory sound is characteristic of a pericardial friction rub, heard best when using the diaphragm of the stethoscope, rather than the bell, and applied with slight pressure on the precordium. Pericardial friction rubs, although heard throughout the precordium, are best heard along the middle to lower sternal borders.

2. c. "J" point elevation in all leads except a VR and frequently [V.sub.1]

The diagnostic electrocardiographic feature of acute pericarditis is elevation of the ST segment (often referred to as "J" point, indicative of the junction when the QRS joins the ST segment) in all leads that reflect the potential electrical variations of the epicardial surfaces of the ventricles. Included are all leads with the exception of aVR and frequently chest lead [V.sub.1], which record the potential electrical variations of the endocardial surfaces of the ventricles as "J" point depression. Equally diagnostic in acute pericarditis is that the "J" point elevation in standard lead II is greater than that in standard lead III. This is because standard lead II is a bipolar lead that records the difference in electrical potentials between 2 sites: aVR with a negative "J" point subtracted from a positive "J" point in aVF (Figure 2).