acute%20pericarditis
ACUTE PERICARDITIS

Pericarditis is the inflammation of the pericardial sac and accounts for 5% of visits to the emergency room for chest pain without myocardial infarction.

The patient experiences chest pain that is sharp, pleuritic and improves with sitting up and leaning forward.

Acute pericarditis is characterized by new-onset pericarditis with at least 2 of the following:

  • Pericarditic chest pain
  • Pericardial friction rubs
  • New or worsening pericardial effusion
  • ECG finding of a new diffuse ST-segment elevation or PR depression

Principles of Therapy

  • Treatment goals are to relieve pain, resolve inflammation and prevent recurrence
  • Specific therapy tailored to the identified etiology or underlying disorder is indicated
  • Choice of therapeutic agent is based on patient’s medical history (prior efficacy or side effects, contraindications), concomitant diseases (preferring Aspirin when it is already used as antiplatelet therapy) and physician’s knowledge and skills

Pharmacotherapy

Aspirin and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • First-line agents for acute pericarditis
  • Aspirin is the preferred agent for patients with pericarditis following myocardial infarction
  • Commonly used NSAIDs include Ibuprofen and Indomethacin
  • Given for 1-2 weeks then tapered until symptoms resolve and serum inflammatory markers improve (consider serum CRP levels in guiding duration of treatment and evaluating efficacy of therapy)
    • 2-4 weeks for recurrent pericarditis
  • Gastroprotection should be considered due to the high doses required
  • Suspect a cause other than postviral or idiopathic if symptoms (eg fever or chest discomfort) persist >1 week or a larger or new pericardial effusion develops during treatment
  • Use is off-label

Colchicine

  • Used as an adjunct to Aspirin and NSAID therapy
  • Helps reduce the rate of recurrence
  • Duration of therapy is up to 3 months
    • Up to 6 months for recurrent pericarditis
  • Well tolerated when given long-term at a low dose
    • Uncommon side effects include hepatic toxicity and myelosuppression
  • Reduce dose in patients with advanced renal dysfunction or those receiving concurrent therapy with P-glycoprotein inhibitors or moderate to strong CYP3A4 inhibitors
  • Use is off-label

Glucocorticoids

  • Given to patients who are intolerant of, refractory to, or have contraindications to Aspirin or NSAIDs and Colchicine
    • Also considered when a specific indication, eg autoimmune disease, is present or an infectious etiology has been excluded
  • Not used as primary therapy in patients with acute pericarditis due to high rate of relapse
  • Given at a low dose for 2 weeks then tapered slowly; 2-4 weeks for recurrent pericarditis
    • In the setting of incomplete response to Aspirin or NSAIDs and Colchicine in patients with recurrent pericarditis, triple therapy with low to moderate-dose steroids added to Aspirin or NSAIDs and Colchicine is given (not to be used as a substitute for these drugs) then tapered with a single drug class at a time before Colchicine is slowly discontinued
    • Slow tapering and a prolonged course of steroid therapy may be required though with potential for steroid-associated side effects and risk of additional recurrences; consider measures for osteoporosis prevention

Other Agents

  • For refractory recurrent pericarditis, other promising therapeutic agents to consider include Azathioprine, intravenous immunoglobulins (IVIG), interleukin-1 (IL-1) antagonist (Anakinra), immunosuppressive drugs [Methotrexate, anti-tumor necrosis factor (TNF) agent, Cyclosporine, Cyclophosphamide, Hydroxychloroquine]
    • In patients with documented corticosteroid-dependent, infection-negative recurrent pericarditis unresponsive to Colchicine, consider giving Azathioprine, IVIG and Anakinra

Surgical Intervention

Pericardiectomy

  • May be performed in patients with refractory recurrent pericarditis or constrictive pericarditis only when a trial of medical therapy had been unsuccessful  
    • May also be done in cardiac tamponade resulting from repeated pericardial effusion recurrences or steroid toxicity limiting additional medical therapy  
  • Results can vary from complete remission to continuing symptoms; complete pericardial resection gives the best outcome  

Pericardial Window

  • Allows drainage of pericardial fluid into the pleural space to prevent tamponade  
  • Considered in patients when catheter drainage persists for >3-4 days  

Interventional Techniques

Pericardiocentesis

  • Echocardiography- or fluoroscopy-guided, it is used for pericardial drainage and biopsy  

Pericardioscopy

  • Visualizes the pericardial sac and enables targeted biopsy

Management of Other Forms of Acute Pericarditis

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

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

  • 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

Prognosis

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

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

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