Overview
Definition:
Pericarditis is inflammation of the pericardium, the double-layered sac surrounding the heart
In adolescents, it is most commonly idiopathic or viral in etiology, presenting with chest pain and characteristic ECG changes.
Epidemiology:
While the incidence varies, viral infections are the most common cause in children and adolescents
Idiopathic cases, often presumed viral, are also frequent
Recurrence is a significant concern.
Clinical Significance:
Prompt diagnosis and appropriate management are crucial to relieve symptoms, prevent complications like cardiac tamponade and constrictive pericarditis, and guide safe return to activities, including sports.
Clinical Presentation
Symptoms:
Retrosternal chest pain, often sharp and pleuritic, worsening with deep inspiration or lying flat
May radiate to the trapezius ridge
Fever, cough, and dyspnea can be present
Recent upper respiratory tract infection is common.
Signs:
Pericardial friction rub, a characteristic scratchy sound heard best at the left sternal border, best heard with the patient leaning forward
Tachycardia
Possible muffled heart sounds
Signs of effusion or tamponade like pulsus paradoxus and Beck's triad (hypotension, muffled heart sounds, jugular venous distension) are late findings.
Diagnostic Criteria:
Diagnosis is typically made with at least two of the following: pericardial chest pain, pericardial friction rub, new or worsening diffuse ST-segment elevation or PR depression on ECG, and new or worsening pericardial effusion on imaging
Fever and evidence of a preceding viral infection support the diagnosis.
Diagnostic Approach
History Taking:
Detailed characterization of chest pain (onset, quality, radiation, exacerbating/alleviating factors)
History of recent viral illness, autoimmune diseases, or trauma
Family history of cardiac conditions
Questions about recent physical exertion or trauma
Red flags: prolonged pain, pleuritic features, positional exacerbation, signs of hemodynamic compromise.
Physical Examination:
Auscultation for pericardial friction rub
Assess for jugular venous distension
Palpate pulses for pulsus paradoxus
Assess respiratory effort and lung sounds to rule out pulmonary causes
Full cardiovascular and pulmonary examination.
Investigations:
Electrocardiogram (ECG): diffuse ST-segment elevation, PR depression
Echocardiography: assessment for pericardial effusion, chamber size, and function, guiding diagnosis and severity
Laboratory tests: Complete blood count (CBC) to assess for infection, inflammatory markers (ESR, CRP) to gauge inflammation, viral serology if indicated, cardiac enzymes to rule out myocardial involvement (myopericarditis).
Differential Diagnosis:
Myocarditis, myocardial infarction, pulmonary embolism, pneumonia, musculoskeletal pain, gastroesophageal reflux disease (GERD), anxiety
Key differentiator for pericarditis is the characteristic positional and pleuritic chest pain, pericardial rub, and ECG changes.
Management
Initial Management:
Pain and symptom relief
Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy
High-dose ibuprofen is typically the first choice
Rest and avoidance of strenuous physical activity are essential.
Medical Management:
NSAIDs: Ibuprofen (e.g., 30-50 mg/kg/day divided into 3 doses, max 2400 mg/day) is the drug of choice
Duration is typically 7-14 days or until symptoms resolve, with gradual tapering
Colchicine is recommended for recurrent pericarditis or as an adjunct for initial episodes to reduce recurrence rates
Corticosteroids are reserved for cases refractory to NSAIDs and colchicine, or in specific etiologies (e.g., autoimmune), due to increased risk of recurrence and complications.
Surgical Management:
Rarely indicated for uncomplicated pericarditis
Surgical pericardiectomy may be considered for chronic constrictive pericarditis
Pericardiocentesis is performed for significant or hemodynamically compromising pericardial effusions, especially in tamponade.
Supportive Care:
Adequate rest
Close monitoring for signs of recurrence or complications
Education regarding the importance of adherence to medication and activity restrictions
Psychological support for the adolescent and family.
Prognosis
Factors Affecting Prognosis:
Etiology (viral/idiopathic generally good prognosis)
Presence of pericardial effusion or tamponade
Recurrence
Underlying comorbidities such as autoimmune disease or malignancy
Adherence to treatment and activity restrictions.
Outcomes:
Most adolescents with idiopathic or viral pericarditis have a favorable outcome with appropriate treatment and recovery of full function
Recurrence is common, affecting 20-30% of patients.
Follow Up:
Regular follow-up appointments are necessary to monitor symptom resolution, assess for recurrence, and guide the gradual return to physical activity
Follow-up typically involves clinical assessment and echocardiography as needed
Gradual increase in activity over several weeks to months is recommended.
Key Points
Exam Focus:
NSAIDs (ibuprofen) are first-line
Colchicine reduces recurrence
ECG changes include diffuse ST elevation and PR depression
Echocardiography is key for effusion/tamponade
Activity restriction is vital for recovery and preventing recurrence
Myopericarditis involves elevated cardiac enzymes.
Clinical Pearls:
Always listen for a pericardial friction rub, which is pathognomonic
Differentiate pleuritic chest pain from other causes
Gradual tapering of NSAIDs is important
Consult cardiology for significant effusions or recurrent episodes.
Common Mistakes:
Delaying NSAID initiation
Inadequate pain control leading to early return to activity
Not considering colchicine for recurrence prevention
Misinterpreting ECG changes
Underestimating the importance of prolonged activity restriction.