Idiopathic Pericarditis

Schwier NC, Cornelio CK, Epperson TM
Managing acute and recurrent idiopathic pericarditis. JAAPA 2020;33:16-22.

The following are key points to remember about this review article on the diagnosis and management of idiopathic pericarditis, which incorporates recommendations from the 2015 European Society of Cardiology guidelines on pericardial disease:

  1. Pericarditis is the most common form of pericardial disease.
  2. The most common etiologies in the United States are viral or idiopathic, which is often of presumed viral etiology. Pericarditis maybe secondary to other infectious and non-infectious causes.
  3. Patients with viral pericarditis often report symptoms of viral infection (similar to upper respiratory tract infection or gastroenteritis) a few weeks prior to pericarditis symptoms.
  4. Diagnosis of pericarditis can be made if a patient has any two of four criteria: characteristic chest pain, electrocardiographic changes (new, widespread ST-segment elevation or PR-segment depression), pericardial friction rub, and new or worsening pericardial effusion. The chest pain is typically sharp, pleuritic, improved by sitting up or leaning forward, and may radiate to the trapezius.
  5. Presence of fever, leukocytosis, high-sensitivity C-reactive protein, or antinuclear antibodies may aid clinicians in determining if pericarditis is due to inflammation or virus.
  6. Pericarditis is classified as acute (initial episode), recurrent (subsequent episode after symptom-free interval of over 6 weeks), incessant (lasting 6 weeks to 3 months), chronic (lasting over 3 months), or constrictive (associated with scarring and inelasticity of the pericardium that eventually results in impaired ventricular filling).
  7. Cardiac tamponade may be associated with acute or chronic pericarditis. Patients who develop cardiac tamponade are at increased risk of mortality.
  8. Colchicine, in combination with aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs), is first-line pharmacotherapy for acute and recurrent idiopathic pericarditis. This combination reduces rate of recurrence within 18 months.
  9. Aspirin/NSAIDs are important in relief of chest pain but do not affect the natural progression of pericarditis. Monotherapy with aspirin/NSAIDs can increase the risk of recurrence.
  10. Choice of therapy should be individualized. However, three-drug therapy with colchicine, aspirin, and NSAIDs has been associated with favorable outcomes.
  11. Steroids are not recommended because they are associated with an increased risk of recurrence of pericarditis. Corticosteroids may be considered in patients not responding to aspirin/NSAIDs and colchicine but only if infectious causes have been ruled out.
  12. Immunotherapies are considered third-line treatment modalities. These include anakinra, azathioprine, and parenteral immunoglobulin.
  13. Physical activity should be restricted in patients with pericarditis until symptoms resolve and high-sensitivity C-reactive protein normalizes. Athletes should restrict physical activity for 3 months.
  14. Surgical therapies include pericardiocentesis, pericardial window, pericardiotomy, and pericardiectomy. Pericardiectomy is reserved for patients with restrictive pericarditis.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease

Keywords: Pericarditis, Pericardium, Pericardial Effusion, Anti-Inflammatory Agents, Non-Steroidal, Aspirin, Colchicine, Chest Pain, Inflammation, Pericardiocentesis, Pericardial Window Techniques, Pericardiectomy

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