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Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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The diagnosis of pericarditis begins with a careful history taken by the health care practitioner. While most cases of pericarditis have an unknown cause, it is important to explore situations where an underlying disease can be treated. History of recent illness, heart attack, surgery, or underlying inflammatory illness may give a clue as to the potential cause of pericarditis.

When a patient has symptoms with chest pain, the health care practitioner will always be concerned about other potential diagnoses including atherosclerotic heart disease with angina or heart attack, aortic dissection, pulmonary embolism, as well as less life-threatening illnesses such as esophagitis and gastritis.

While physical examination will concentrate on the heart examination, general assessment of the patient may find the presence of fever, a rapid heartbeat (tachycardia) or rapid breathing rate (tachypnea).

Abnormal heart sounds may be heard when using a stethoscope to listen to the heart. Hearing a friction rub often confirms the presence of pericarditis, though not the cause. A friction rub occurs when the two inflamed pericardial surfaces, rub against each other with every heart beat. The friction rub which can be difficult to hear, may sometimes be better heard when the patient leans forward.

Beck's triad describes the signs of cardiac tamponade on physical examination. Low blood pressure, jugular vein distention in the neck and muffled heart tones make up the triad. The tamponade prevents the heart from distending to accept blood returning from the body, causing veins to distend. The heart cannot pump blood appropriately causing the blood pressure to fall and the fluid decreases the heart sound volume making it difficult to he heard by the health care practitioner.

An electrocardiogram (EKG) may reveal common electrical conduction abnormalities that are seen in pericarditis.

Chest X-rays may be normal, but if there is a significant pericardial effusion, the heart shape may be abnormal. It is sometimes described as globular or flask shaped.

An echocardiogram or ultrasound exam of the heart may demonstrate fluid or effusion. It is an emergent test if cardiac tamponade is suspected.

While the diagnosis of pericarditis is often made clinically and confirmed with an electrocardiogram or other tests such as CT scan, ultrasound, or echocardiogram, blood tests may be helpful in the diagnosing the underlying cause.

• A complete blood count (CBC) may reveal an elevated white blood cell count associated with a potential bacterial infection, though the white cell count may be elevated due to stress.
  
  
• Blood chemistry tests can evaluate kidney function to explore for uremia (excessive amounts of urea in the blood) or kidney failure.
  
  
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are non-specific markers for inflammation within the body.
  
  
• Cardiac enzymes such as troponin or myoglobin may be measured since pericarditis may be associated with heart attack or myocarditis (an inflammation of the heart muscle).
  
  
• Other laboratory tests may be considered depending upon the situation and may include blood cultures for bacterial or viral infections, tuberculin testing, and thyroid function tests among others.

Other tests may be used to further define the extent and in some cases, the source of pericardial fluid. Most frequently, CT or MRI scans of the heart and surrounding structures are examined.

In certain situations such as pericardial tamponade, pericardiocentesis may be performed. A long needle is inserted through the chest wall into the pericardial space and fluid is removed to reduce pressure on the heart muscle tissue and allow the heart to beat properly. This fluid can be sent for analysis to explore possible infections, abnormal cells, and other causes of inflammation.

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