Management of Acute and Recurrent Pericarditis

Chiabrando JG, Bonaventura A, Vecchié A, et al.
Management of Acute and Recurrent Pericarditis. J Am Coll Cardiol 2020;75:76-92.

The following are key points to remember about this state-of-the-art review on management of acute and recurrent pericarditis:

  1. Pericarditis refers to inflammation of the pericardial layers and is the most common form of pericardial disease. Causes may be infectious (tuberculosis remains the most common cause in developing countries) or noninfectious, but most cases remain idiopathic.
  2. The diagnosis of acute pericarditis should be based on the presence of at least two of the following four criteria: 1) characteristic chest pain, 2) pericardial friction rub, 3) characteristic electrocardiographic changes, and 4) new or worsening pericardial effusion. Laboratory workup, including assessment for inflammation and myocardial damage, is also recommended. Cardiac magnetic resonance (CMR) may be helpful when the diagnosis is uncertain, echocardiographic imaging is challenging, or myocardial involvement is suspected.
  3. Most cases of pericarditis may be managed in the outpatient setting. Patients with one of the following high-risk features, however, should be admitted to the hospital for treatment: high fever (>38°C), subacute onset, large pericardial effusion or tamponade, lack of response to anti-inflammatory therapy after 1 week of treatment, and evidence for myocardial involvement. Additional predictors of elevated risk include immunosuppression, oral anticoagulation, and trauma.
  4. Acute pericarditis should be treated with a nonsteroidal anti-inflammatory drug (NSAID), typically with a 2- to 4-week taper after the resolution of symptoms. In addition, a 3-month course of colchicine (with weight-adjusted dosing) is recommended to reduce the risk of recurrent pericarditis. Strenuous activity should be avoided.
  5. Corticosteroids have been associated with a more prolonged disease course and a higher risk of recurrence. Accordingly, their use (at low doses) should be reserved for patients unable to take NSAID therapy or for those with specific indications (e.g., autoimmune disease, pregnancy, or immune checkpoint inhibitor-associated pericarditis).
  6. Purulent pericarditis is a rare but potentially life-threatening disease. It requires specific antimicrobial treatment according to the causative etiologic agent, along with pericardial drainage.
  7. Recurrent pericarditis may occur in up to 30% of patients after an initial episode of acute pericarditis. Treatment should consist of an NSAID, typically with a 2- to 4-week taper after the resolution of symptoms, along with at least 6 months of colchicine (with weight-adjusted dosing). Corticosteroids (at low doses) should be reserved for those who have failed multiple attempts at therapy with an NSAID plus colchicine. Anti-interleukin 1 therapy (e.g., anakinra and rilonacept) has been shown to be beneficial in patients with refractory, corticosteroid-dependent disease. Other options for consideration in refractory disease include azathioprine, methotrexate, mycophenolate mofetil, and intravenous immunoglobulins. Surgical pericardiectomy is considered a last option.
  8. When tamponade complicates pericarditis, immediate drainage is indicated. In most cases, drainage is accomplished percutaneously with imaging guidance; some cases require surgical management.
  9. Constrictive pericarditis is a possible complication of nearly any pericardial disease process. Diagnosis may be challenging, and rests on integration of bedside features with characteristic echocardiographic findings. CMR is helpful to confirm the diagnosis and to assess for pericardial inflammation (shown by late gadolinium enhancement of the pericardium). Complex hemodynamic catheterization may be necessary when the noninvasive assessment is inconclusive.
  10. When there is evidence of inflammatory constrictive pericarditis, a course of anti-inflammatory therapy is indicated, in addition to cautious diuresis in patients with evidence of volume overload. When the constrictive process is chronic, without evidence for active inflammation, radial pericardiectomy may be required.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Anticoagulants, Anti-Infective Agents, Anti-Inflammatory Agents, Anti-Inflammatory Agents, Non-Steroidal, Autoimmune Diseases, Azathioprine, Cardiac Tamponade, Catheterization, Chest Pain, Colchicine, Diagnostic Imaging, Echocardiography, Gadolinium, Immunoglobulins, Intravenous, Inflammation, Interleukin 1 Receptor Antagonist Protein, Magnetic Resonance Imaging, Pericardial Effusion, Pericardiectomy, Pericarditis, Pericarditis, Constrictive, Pericardium, Primary Prevention, Tuberculosis

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