Acute%20pericarditis Management

Acute Viral Pericarditis

• Self-limiting disease treated with a short course of NSAID therapy and adjunctive Colchicine for recurrence prevention
• Corticosteroids are not given as these may reactivate viral infections and result in ongoing inflammation

Bacterial Pericarditis

• Tuberculous pericarditis is most common in developing countries
• Empiric anti-TB chemotherapy is recommended for exudative pericardial effusion in endemic areas after excluding causes such as autoimmune diseases, malignancy, purulent pericarditis, uremia and trauma
• HIV-negative cases of TB pericarditis may be given adjunctive steroids
• If with cardiac tamponade, pericardiocentesis may be performed 

Constrictive Pericarditis

• Can occur after any pericardial disease but rarely develops after recurrent pericarditis
  • Risk is low (1%) in patients with viral and idiopathic pericarditis, intermediate (2-5%) for neoplastic, autoimmune and immune-mediated etiologies, and high (20-30%) for bacterial causes, eg TB and purulent pericarditis
• It is recommended to medically treat specific conditions (eg tuberculous pericarditis) to avoid progression of constriction and to control symptoms of congestion
• Effusive-constrictive pericarditis may be treated with pericardiocentesis, chronic permanent constriction with pericardiectomy

Drug-related Acute Pericarditis and Pericardial Effusion

• Damage to the pericardium is associated with “serum sickness” brought about by blood products, direct pericardial applications of talc or magnesium silicate, sclerosants, asbestos and iron in beta thalassemia
• Anticoagulant therapies may cause hemorrhagic or worsening pericardial effusion that may lead to cardiac tamponade, though this is not supported by current available data
• Management is stopping the causative agent and administering symptomatic treatment

Fungal Pericarditis

• Rare form of pericarditis which may be caused by Histoplasma (in immunocompetent patients), Aspergillus or Candida sp (in immunocompromised patients)
• May be treated with NSAIDs; consider antifungal therapy for disseminated histoplasmosis

Malignant Pericarditis

• May be due to metastasis from a primary tumor [eg breast cancer, lymphoma, leukemia, melanoma (less common)]
• Pericardiocentesis or drainage if pericardial effusion is present

Myopericarditis

• It is pericarditis with concomitant myocardial inflammation but normal ventricular function
• Most common causes are viral infections in developed countries while other infectious causes, eg TB, are common in developing countries
• Management is similar to that of acute pericarditis: Exercise restriction, empiric Aspirin or NSAID therapy for chest pain and corticosteroids in cases of intolerance, contraindications or failure of Aspirin or NSAIDs
  • Data to recommend Colchicine use is insufficient

Purulent Pericarditis

• May be due to a direct extension from bacterial pneumonia or pleural empyema 
• Management is with surgical drainage of effusion and IV antibiotics
• Dense adhesions and thick purulent effusions may require pericardiectomy for adequate drainage and prevention of constriction

Radiation Pericarditis

• Acute pericarditis with or without effusion may develop following chest radiation
• Management includes reduction in dose and volume of cardiac irradiation and pericardiectomy due to radiation-induced constrictive pericarditis

Systemic Autoimmune and Autoinflammatory Diseases

• Pericardial involvement may be present in patients with Behcet’s syndrome, inflammatory bowel disease, rheumatoid arthritis, sarcoidosis scleroderma, Sjogren’s syndrome, systemic lupus erythematosus and systemic vasculitis
• Treatment is with control of the systemic disease, may also consider anti-IL or anti-TNF therapeutic agents

Post-Cardiac Injury Syndromes

• Autoimmune pathology in a group of pericardial syndromes which include post-MI pericarditis (Dressler syndrome), post-pericardiotomy syndrome, post-traumatic pericarditis
• Treatment is based on empiric anti-inflammatory therapy

Pericarditis in Renal Failure

• Has 3 different pathologies: Uremic pericarditis (pericarditis before dialysis or within 8 weeks of initiation of dialysis), dialysis pericarditis (occurs ≥8 weeks after initiation of dialysis) and constrictive pericarditis
• Consider dialysis in uremic pericarditis and intensify dialysis for those patients who develop pericarditis despite ongoing renal replacement therapy

Acute Pericarditis

• Long-term prognosis is good for patients with idiopathic or presumed viral pericarditis
• Cardiac tamponade and constrictive pericarditis are more common in patients with underlying specific etiology
  • The possibility of constriction is related to the cause or etiology of pericarditis (eg TB or bacterial infection, cardiac surgery, trauma) and not to the number of episodes

Recurrent Pericarditis

• Rates of complication are related to the cause or etiology and not to the frequency of recurrences
• Severe complications and cardiac tamponade are rare while constrictive pericarditis has never been documented