Pericarditis, Acute Inflammatory

Causes

• Infections

• Autoimmune diseases

• Uremia

• Neoplasms

• Radiation

• Drug toxicity

• Hemopericardium

• Postcardiac surgery

• Contiguous inflammatory processes of the heart or lung (eg, myocardial infarction [MI], Dressler syndrome, idiopathic)

Viral infections are the most common cause; acute pericarditis often follows upper respiratory tract infection

Males, usually younger than age 50, are most commonly affected

Often associated with pleuritic chest pain, relieved by sitting, that radiates to the neck, shoulders, back, or epigastrium

Dyspnea and fever

Pericardial friction rub with or without evidence of pericardial effusion or constriction

Pericardial involvement

Tuberculous pericarditis: subacute; symptoms may be present for days to months

Bacterial pericarditis: rare; patients appear toxic and are often critically ill

Uremic pericarditis: symptoms may or may not be present; fever is absent

Neoplastic pericarditis: often painless, hemodynamic compromise

Dressler syndrome (post-MI pericarditis)

• Occurs within days to 3 months post-MI

• Usually self-limited

Usually clinical

Leukocytosis

ECG

• Generalized ST-T wave changes, characteristic progression beginning with diffuse ST elevations, followed by a return to baseline, then T wave inversions

• PR depression indicates atrial injury

Chest radiograph

• Frequently normal

• Cardiac enlargement if pericardial effusion

• Signs of related pulmonary disease

Echocardiogram

• Often normal in inflammatory pericarditis

• Otherwise, can demonstrate pericardial effusion, tamponade

Erythrocyte sedimentation rate or inflammatory C-reactive protein usually elevated

The American Society of Echocardiography proposes adding an elevated C-reactive protein and late gadolinium enhancement of the pericardium to confirmatory diagnostic criteria

Screening chest CT or MRI is often recommended to ensure there is no extracardiac diseases contiguous to the pericardium

PET scanning can also be used to help define pericardial inflammation

Rising titers in paired sera may confirm viral infection but are rarely done

Cardiac enzymes slightly elevated if there is an epicardial myocarditis component

Cytology of pericardial effusion or pericardial biopsy may be helpful

Usually data from a diagnostic pericardial tap is unhelpful in diagnosis

MRI and CT scan can visualize adjacent tumor when present

Restrict activity until symptom resolution; for athletes, exercise should be restricted until symptoms resolve and all laboratory tests are normal (generally 3 months)

The 2015 European Society of Cardiology guidelines

• Aspirin, 750–1000 mg every 8 hours for 1–2 weeks, tapering the dose by 250–500 mg every 1–2 weeks or

• Ibuprofen, 600 mg every 8 hours for 1–2 weeks, tapering the dose by 200–400 mg every 1–2 weeks

• Gastroprotection should be included

Colchicine

• Initial treatment of the acute episode helps prevent recurrences

• Should be added to the NSAID at 0.5–0.6 mg once daily for patients < 70 kg or twice daily for patients > 70 kg and continued for 3 months

• In all refractory and recurrent cases, colchicine should also be the initial therapy and used for at least 6 months

• The C-reactive protein is used to assess the effectiveness of therapy and, once normalized, tapering is initiated

• Tapering of colchicine is not mandatory

Indomethacin, 25–50 mg every 8 hours, can be considered in recurrent pericarditis in place of ibuprofen

Aspirin and colchicine should be used instead of NSAIDs in postmyocardial infarction pericarditis (Dressler syndrome)

• Aspirin: 750–1000 mg three times daily for 1–2 weeks plus

• Colchicine: 3 months

Systemic corticosteroids (eg, prednisone 0.25–0.5 mg/kg/day orally, tapering over 4–6 weeks) can be used in patients with severe symptoms, in refractory cases, or in patients with immune-mediated etiologies, but such therapy may entail a higher risk of recurrence and colchicine is recommended in addition for 3 months, to help prevent recurrences

Pericardial stripping may be considered if colchicine plus more significant immunosuppression fails