What is the workup for pericarditis (inflammation of the pericardium)?

From the Guidelines

The workup for pericarditis should begin with a first diagnostic evaluation including auscultation, ECG, transthoracic echocardiography, chest X-ray, and routine blood tests, including markers of inflammation, as recommended by the 2015 ESC guidelines 1. The initial evaluation should focus on identifying signs and symptoms of pericarditis, such as chest pain, fever, and pericardial friction rub.

• Key components of the initial workup include:
  • Auscultation to detect pericardial friction rub
  • ECG to look for diffuse ST-segment elevation and PR depression
  • Transthoracic echocardiography to evaluate for pericardial effusion and cardiac tamponade
  • Chest X-ray to assess for an enlarged cardiac silhouette
  • Routine blood tests, including:
    • Markers of inflammation (CRP and/or ESR)
    • White blood cell count with differential count
    • Renal function and liver tests
    • Myocardial lesion tests (CK, troponins) The search for independent predictors of an identifiable and specifically treatable cause of pericarditis is crucial, including factors such as fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs 1.
• Second-level testing, such as CT and/or CMR, may be recommended for further diagnostic workup in pericarditis, especially in cases where the diagnosis remains unclear or in high-risk patients 1. It is essential to consider pericardiocentesis or surgical drainage in cases of cardiac tamponade or suspected bacterial and neoplastic pericarditis, and percutaneous or surgical pericardial biopsy may be considered in selected cases of suspected neoplastic or tuberculous pericarditis 1.

From the Research

Diagnosis of Pericarditis

• The diagnosis of pericarditis requires at least two of the following criteria: new or worsening pericardial effusion, characteristic pleuritic chest pain, pericardial friction rub, or electrocardiographic changes, including new, widespread ST elevations or PR depressions 2.
• Transthoracic echocardiography should be performed in all patients with acute pericarditis to characterize the size of effusions and evaluate for complications 2.
• Pericardial friction rubs are highly specific but transient, and they have been reported in 18% to 84% of patients with acute pericarditis 2.
• Classic electrocardiographic findings include PR-segment depressions; diffuse, concave, upward ST-segment elevations without reciprocal changes; and T-wave inversions 2.

Treatment of Pericarditis

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment option for pericarditis 2.
• Colchicine should be used in combination with first- or second-line treatments to reduce the risk of recurrence 3, 2.
• Glucocorticoids should be reserved for patients with contraindications to first-line therapy and those who are pregnant beyond 20 weeks' gestation or have other systemic inflammatory conditions 2.
• Aspirin and NSAIDs are the mainstay of therapy, with the possible adjunct of colchicine, especially for recurrences 4.
• Corticosteroids are a second choice for difficult cases requiring multi-drug therapies and specific medical conditions 4.

Risk Stratification and Management

• Patients with a higher risk of complications should be admitted to the hospital for further workup and treatment 2.
• The development of constrictive pericarditis and pericardial tamponade can be life-threatening, and occur in less than 0.5% and less than 3% of patients with acute pericarditis, respectively 3.
• Tuberculosis is the most common cause of pericarditis in endemic areas, and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis 3.