2. Case 1
53 y F with 3/12 CP typical to pericarditis attack
6/12 ago that was treated with ASA only for 14
days with complete recovery.
Normal physical exam no rub
Normal WBC and ESR
Normal ECG
ECHO: no PE
3. Does she have recurrent
pericarditis?
How would you treat her?
4. Case 2
48 y M with with 1 attack of pericarditis
4/12(treated with ASA with no good
response ) ,came with SOB and extensional CP
similar to his previous attack.
V/S stable no rub
ECHO : 0.7 cm effusion
WBC 14 , CK and trop –ve.
7. Case 3
68 y M with RA. Referred by GP with CP
(pericarditis).
Required multible steroid courses for RA.
On going similar pain for 6/12 treated by his
rheumatologist with steroid( 40 mg for 14 days).
v/s stable no rub
ECG non specific T changes
ESR 82.
ECHO : diastolic dysfunction with 1 cm PE with no
increase in ICP
9. Recurrent Pericarditis
Objectives
How to make the diagnosis?
How is at risk?
Prognosis
Treatment options
Guideline
10. Definition
Need 1 + 2 + any of 3
1) A documented first attack of acute pericarditis
2) Recurrent pain
3) Fever
Friction rub
ECG changes
Pericardial effusion
Elevation WBC or ESR or CRP
12. Causes of recurrence …
(i) insufficient dose or treatment duration of the
previous attack.
(ii) early corticosteroid treatment causing
augmented viral DNA/RNA replication in the
pericardial tissue leading to increased viral
antigen exposure.
(iii) exacerbation of an underlying connective
tissue disease .
13. Work up …
Often negative
Not recommended to consider routine
pericardial tap for diagnostic purpose
Work up for infectious and or CT causes are
guided by clinical picture
Mayo Clin Proc 2002 Jan;77(1):39-43
Am J Cardiol. 2006 Jul 15;98(2):267-71
Am J Cardiol 2005 Sep 1;96(5):736-9
14. Course and types
The first symptoms of recurrent pericarditis occur at a
variable time after the initial attack, but usually within
18 to 20 months.
1)The intermittent form, symptoms start after a symptom-
free interval longer than six weeks after drug
withdrawal .
2)The incessant form, symptoms appear within six weeks
after drug discontinuation or during attempted
weaning.
15. Symptoms
The most frequent symptom of recurrent
pericarditis is chest pain.
Typically sharp improve with sitting
Mimic angina (exertional) once chronic .
16. Answer this ..
………. is the most common cause of SOB in patients
with recurrent pericarditis .
A) Tamponade
B) Constrictive pericarditis
C) All of above
D) Non of the above
Answer is D
17. Complications
31 patients , follow up for 2-19y :
3 patients had Tamponade initially
None during recurrence
No constriction
J Am Coll Cardiol 1986 Feb;7(2):300-5
18. Complications
221 patients , 5 years f/u
15 patients , 8 years f/u
J Am Coll Cardiol. 2003 Aug 20;42(4):759-64. JACC Vol. 43, No. 6, 2004 March 17, 2004:1042–6
19. Prognosis
Prognosis is excellent for most patients with
idiopathic recurrent pericarditis.
Severe complications are uncommon even with
multiple recurrences
Not associated with myocardial systolic or
diastolic dysfunction
Rarely associated with constriction .
Quality of life can be severely affected
Mayo Clin Proc 2002 Jan;77(1):39-43
Am J Cardiol. 2006 Jul 15;98(2):267-71
Am J Cardiol 2005 Sep 1;96(5):736-9
21. Predictors of recurrence
No presenting clinical feature of an initial
episode of acute pericarditis reliably predicts
recurrence.
The response to therapy and type of therapy for
the initial episode may have some prognostic
value.
22. 1) Failure of NSAID
254 patients , 5 years f/u
J Am Coll Cardiol 2004 Mar 17;43(6):1042-6.
23. 2) Steroid therapy
294 patients , 5 years f/u
Am J Cardiol 2005 Sep 1;96(5):736-9.
26. Before that…
Recurrent pericarditis can be a prolonged and
frustrating disease to patients and doctors.
Because of this and the need to maintain
compliance, effective communication with the
patient is important.
27. Things to keep in mind…
Further recurrences are possible
Not always the same etiology
Good prognosis
The possibility of pericardiectomy
Complications of immunosuppressant
Out patient therapy
31. 48 patients, 4 years f/u
CORE
Am J Cardiol. 2005 Sep 1;96(5):736-9
32. Recommended dose for Colchicine
> 70 kg 2 mg/day for 1-2 days, followed dose of
1 mg/day for 6/12 plus NSAID and at least for
3/12.
< 70 kg 1 mg/day for 1-2 days followed by 0.5
mg/daily for 6/12 plus NSAID at least for
3/12.
Bone marrow suppression, hepatotoxicity,
muscle and kidney toxicity
33. NSAID
The patient's prior experience can provide a
useful guide.
If a patient reports that a specific NSAID drug
has proven effective, it is reasonable to use that
agent.
This approach should be maintained until it is
clear that NSAIDs have failed to control the
syndrome, especially the pain, or that the drugs
are not tolerated.
34. Recommended NSAID
Ibuprofen 800 mg four times daily then 600 mg
four times daily at two weeks and to 400 mg
four times daily at four weeks.
ASA 2.0 to 4.0 g/day in divided doses for
patients with CAD.
Treatment is discontinued after 3/12. Slow
tapering is recommended in an attempt to
reduce the subsequent recurrence rate.
Prophylactic PPI
35. Steroids are not bad…but
Glucocorticoid therapy should generally be
avoided in patients with recurrent pericarditis
May be required to treat patients who fail
NSAID and/or colchicine therapy.
Common mistakes are to use too low dose and,
more often, to taper the dose too rapidly
36. High vs. low steroid dose
and duration
12 patients
J Am Coll Cardiol 2005 Nov 1;26(5):1276-9.
37. Tapering the dose
Prednisone 1-1.5/kg/day is the ideal .
Tapered 10 mg/day every one to two weeks
for total of 3/12
Each decrement in steroid dose should proceed
only if the patient is asymptomatic and C-
reactive protein is normal.
38. Toward the end of the taper, NSAID or
colchicine should be introduced to complete 3-
6/12 if needed.
If symptoms recur every effort should be made
not to increase or reinstitute corticosteroids, but
instead control symptoms with NSAID.
Osteoporosis prevention
39. Immunosuppressant
The ESC guidelines recommend azathioprine
(75 to 100 mg/day).
Methotrexate
Cyclophosphamide
IG
43. A difficult management .
This problem is most likely to occur in more
chronic cases in which numerous recurrences
have been suppressed by steroid.
Pain management should be initiated
Pain management begins with Tylenol
Pain service
Watch for recurrence.
44. Case 1
53 y F with 3/12 CP typical to pericarditis attack
6/12 ago that was treated with ASA only for 14
days with complete recovery.
Normal physical exam no rub
Normal WBC and ESR
Normal ECG
ECHO: no PE
45. Does she have recurrent
pericarditis?
How would you treat her?
46. NO
Reassurance
Tylenol and NSAID as needed
Pain service
Follow up with GP keeping in mind referral to
cardiology for more objective findings .
47. Case 2
48 y M with with 1 attack of pericarditis
4/12(treated with ASA with no good
response ) ,came with SOB and extensional CP
similar to his previous attack.
V/S stable no rub
ECHO : 0.7 cm effusion
WBC 14 , CK and trop –ve.
51. Case 3
68 y M with RA. Referred by GP with CP
(pericarditis).
Required multible steroid courses for RA.
On going similar pain for 6/12 treated by his
rheumatologist with steroid( 40 mg for 14 days).
v/s stable no rub
ECG non specific T changes
ESR 82.
ECHO : diastolic dysfunction with 1 cm PE with no
increase in ICP
52. How would you treat him ?
What predicts recurrence ?
53. NSAID and colchicine for 3-6/12
No steroid after talking to rheumatologist .
After 1/12 pain got wore despite ASA and
colchicine .
Switched to prednisone 70mg/day tapered
slowly over 3/12 .