Pericarditis | Spoon-Feed Review

April 17, 2020

Written by Thomas Davis

Spoon Feed
If you primarily rely on the ECG to rule in/out pericarditis, then you need to read this JACC summary to learn how to diagnose and manage pericarditis like an expert.

Why does this matter?
Pericarditis is common. You will see this if you train yourself to spot it. Even routine cases may rarely cause tamponade. Recognition is also important to guide patients to avoid exercise and treat the underlying inflammation.

Pericarditis – what you need to know

Etiology

• Viruses — most commonly identified etiology in developed countries 

• TB — most commonly identified etiology in developing countries 

• Bacterial 

• Post cardiac procedure injury 

• Auto-immune 

• Hypothyroid 

• Neoplastic 

• Radiotherapy 

• Immune checkpoint inhibitors  

• Idiopathic 

Diagnosis and Workup

Based on ESC guidelines, pericarditis is diagnosed when 2 of the 4 diagnostic criteria are met.

1. Chest pain: Classically but not always, this is sharp pain with rapid onset. Pain may improve with leaning forward.

2. Friction rub: Best heard when leaning forward and along the left sternal border.

3. ECG changes:  Classic changes are only seen 60% of the time. 

4. Pericardial effusion

Biomarkers

• Troponin is not a negative prognostic marker even though it defines myopericarditis. 

• CRP elevation predicts recurrence but also responsiveness to anti-inflammatory therapy.

Echocardiogram  

• This is often only test that is needed. 

• It is required on all patients to identify complications. 

Disposition

Admit patients if there is suspicion of an underlying cause (e.g. malignancy or TB) or if they have one of the major predictors of poor outcomes:

• Fever > 38C 

• Subacute onset over several days to weeks 

• Large effusion > 20mm on echocardiogram or evidence of tamponade 

• No response to initial anti-inflammatory therapy 

Treatment

• NSAIDs

  • First line although RCT data are lacking

  • Gradually taper over weeks when pain resolves and CRP normalizes 

• Colchicine

  • Hastens resolution and decreases recurrence

  • Use in conjunction with NSAIDs

  • Adjust for weight

  • Use for at least 3 months

• Steroids

  • Avoid in most cases of pericarditis because it is associated with prolonged disease course and higher recurrence rates.

  • However, consider use in 3 situations:

    1. Immune checkpoint inhibitor pericarditis

    2. Autoimmune pericarditis

    3. Failed or incomplete response to other anti-inflammatory therapies

• Lifestyle modification

  • Athletes should avoid competitive physical activity for at least 3 months to avoid sheer stress on the pericardium.

Source
Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review.  J Am Coll Cardiol. 2020 Jan 7;75(1):76-92. doi: 10.1016/j.jacc.2019.11.021.

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