Understanding Acute Pericarditis: Symptoms and Treatment

Acute pericarditis is an inflammatory condition that affects the pericardium, the two-layered sac surrounding the heart. This condition can lead to significant discomfort and potentially severe complications if not promptly diagnosed and treated. This article delves into the symptoms, diagnosis, and treatment of acute pericarditis, providing a comprehensive understanding of this medical condition.

What is Acute Pericarditis?

Acute pericarditis refers to the sudden onset of inflammation of the pericardium. The pericardium has two layers: the visceral pericardium, which is in direct contact with the heart, and the parietal pericardium, which forms the outer fibrous sac. Between these layers is a small amount of lubricating fluid that allows the heart to move smoothly within the chest cavity. Inflammation can lead to an increase in this fluid and subsequent pericardial effusion, further complicating the clinical picture.

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Causes of Acute Pericarditis

The etiology of acute pericarditis is diverse, encompassing infectious, non-infectious, and idiopathic causes. The most common causes include:

Infectious Agents: Viral infections (e.g., Coxsackievirus, Echovirus), bacterial infections (e.g., Tuberculosis, Staphylococcus), fungal infections, and parasitic infections.
Non-Infectious Causes: Autoimmune diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis), uremia, post-myocardial infarction (Dressler's syndrome), trauma, and neoplasms.
Idiopathic: In many cases, the precise cause remains unidentified, and these are termed idiopathic pericarditis.

Symptoms of Acute Pericarditis

Chest Pain

The hallmark symptom of acute pericarditis is sharp, pleuritic chest pain. This pain is typically exacerbated by deep breathing, coughing, or lying down and relieved by sitting up and leaning forward. The location of the pain is usually retrosternal, but it can radiate to the neck, shoulders, or back, mimicking myocardial infarction.

Pericardial Friction Rub

A pericardial friction rub is a distinctive physical examination finding in acute pericarditis. It is a scratchy, grating sound heard best with the diaphragm of the stethoscope placed at the left lower sternal border. This sound is produced by the inflamed pericardial layers rubbing against each other.

Additional Symptoms

Other symptoms may include fever, malaise, myalgia, and in severe cases, signs of cardiac tamponade such as hypotension, jugular venous distension, and muffled heart sounds.

Diagnosis of Acute Pericarditis

Electrocardiogram (ECG) Changes

The electrocardiogram (ECG) is a crucial diagnostic tool for acute pericarditis. Typical ECG changes in acute pericarditis progress through four stages:

Stage I: Diffuse ST-segment elevation and PR-segment depression.
Stage II: Normalization of ST and PR segments.
Stage III: T-wave inversion.
Stage IV: Resolution of T-wave changes.

These ECG findings help differentiate acute pericarditis from other causes of chest pain, such as myocardial infarction.

Laboratory Tests

Laboratory tests can support the diagnosis of acute pericarditis. Elevated inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are common. Cardiac biomarkers like troponin may also be elevated, indicating myocardial involvement.

Imaging Studies

Echocardiography is essential for assessing pericardial effusion and evaluating the presence of cardiac tamponade. Chest X-rays can reveal cardiomegaly if significant pericardial effusion is present, but they are generally less specific.

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Treatment for Acute Pericarditis

Pharmacological Treatment

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): First-line treatment includes NSAIDs such as ibuprofen or aspirin to reduce inflammation and alleviate pain. Colchicine is often added to NSAID therapy to decrease the recurrence rate.
Corticosteroids: Used in cases refractory to NSAIDs and colchicine or when NSAIDs are contraindicated. However, corticosteroids are associated with a higher recurrence rate and should be used cautiously.
Antibiotics: In cases where bacterial infection is identified or strongly suspected, appropriate antibiotic therapy should be initiated.

Non-Pharmacological Treatment

Rest: Patients are advised to rest until symptoms resolve to prevent exacerbation of inflammation.
Monitoring: Regular follow-up is crucial to monitor the resolution of symptoms and detect any potential complications.

Treatment of Complications

Pericardial Effusion: Small effusions may resolve spontaneously, but large or symptomatic effusions may require pericardiocentesis to prevent cardiac tamponade.
Cardiac Tamponade is a medical emergency requiring immediate pericardiocentesis or surgical intervention to relieve the pressure on the heart.

Complications of Acute Pericarditis

Complications can arise if acute pericarditis is not adequately managed. These include:

Recurrent Pericarditis: This can occur in up to 30% of cases, often within weeks to months of the initial episode.
Cardiac Tamponade: Accumulation of fluid under pressure can impair cardiac filling and output, leading to a life-threatening situation.
Constrictive Pericarditis: Chronic inflammation can lead to fibrosis and thickening of the pericardium, restricting heart movement and causing heart failure symptoms.

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