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Evaluation and Treatment of Pericarditis A Systematic Review

Massimo Imazio, MD1; Fiorenzo Gaita, MD2; Martin LeWinter, MD3
[+] Author Affiliations
1Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Pediatrics, University of Torino, Torino, Italy
2University Division of Cardiology, Department of Medical Sciences, Città della Salute e Della Scienza, University of Torino, Torino, Italy
3Cardiology Unit, University of Vermont College of Medicine and University of Vermont Medical Center, Burlington
JAMA. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763.
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Importance  Pericarditis is the most common form of pericardial disease and a relatively common cause of chest pain.

Objective  To summarize published evidence on the causes, diagnosis, therapy, prevention, and prognosis of pericarditis.

Evidence Review  A literature search of BioMedCentral, Google Scholar, MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews was performed for human studies without language restriction from January 1, 1990, to August 31, 2015. After literature review and selection of meta-analyses, randomized clinical trials, and large observational studies, 30 studies (5 meta-analyses, 10 randomized clinical trials, and 16 cohort studies) with 7569 adult patients were selected for inclusion.

Findings  The etiology of pericarditis may be infectious (eg, viral and bacterial) or noninfectious (eg, systemic inflammatory diseases, cancer, and post–cardiac injury syndromes). Tuberculosis is a major cause of pericarditis in developing countries but accounts for less than 5% of cases in developed countries, where idiopathic, presumed viral causes are responsible for 80% to 90% of cases. The diagnosis is based on clinical criteria including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion. Certain features at presentation (temperature >38°C [>100.4°F], subacute course, large effusion or tamponade, and failure of nonsteroidal anti-inflammatory drug [NSAID] treatment) indicate a poorer prognosis and identify patients requiring hospital admission. The most common treatment for idiopathic and viral pericarditis in North America and Europe is NSAID therapy. Adjunctive colchicine can ameliorate the initial episode and is associated with approximately 50% lower recurrence rates. Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine. Recurrences may occur in 30% of patients without preventive therapy.

Conclusions and Relevance  Pericarditis is the most common form of pericardial disease worldwide and may recur in as many as one-third of patients who present with idiopathic or viral pericarditis. Appropriate triage and treatment with NSAIDs may reduce readmission rates for pericarditis. Treatment with colchicine can reduce recurrence rates.

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Figure 1.
Widespread ST-Segment Elevation and PR-Segment Depression in a 12-Lead Electrocardiogram From a Patient With Acute Pericarditis

Widespread ST-segment elevation, considered characteristic of pericarditis, can be found in no more than 60% of patients with acute pericarditis and is more common in younger male patients, especially in association with myocarditis.3,51 PR depression is especially evident in inferior leads (II, aVF, III) and precordial leads (V2-V6). Electrocardiogram (ECG) findings may be affected by timing in the course of the disease and by treatment. Early in the disease, ECG changes may include ST-segment elevation. Later in the disease and in chronic pericarditis, the ECG may be normal or have negative T waves, reflecting an ECG in evolution. In patients with a rapid response to medical therapy and in mild acute pericarditis, the ECG may be normal. Thus, a normal ECG does not exclude pericarditis.

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Figure 2.
Transthoracic 2-Dimensional Echocardiogram Images From 2 Patients With Acute Pericarditis

A, Parasternal long axis view showing “dry” (without pericardial effusion) acute pericarditis characterized by increased brightness of the pericardial layers, a nonspecific echocardiographic sign associated with fibrinous pericarditis. B, Parasternal long axis view showing a moderate (10-20 mm of telediastolic echo-free space) pericardial effusion. Semiquantitative assessment of pericardial effusion is performed measuring the largest telediastolic echo-free space in different echocardiographic views. A mild effusion is defined as <10 mm; moderate, between 10 and 20 mm; and large, >20 mm.5,19 A large effusion is associated with an increased risk of complications and with specific etiologies (nonidiopathic pericarditis; nonviral pericarditis). About 60% of patients with acute pericarditis will have a pericardial effusion, generally mild.5,19 The absence of a pericardial effusion does not exclude pericarditis. LA indicates left atrium; LV, left ventricle.

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Figure 3.
Posterior-Anterior Chest Radiograph of a Patient With Acute Pericarditis

Water bottle–shaped cardiac silhouette characteristic of a large pericardial effusion in a patient with acute pericarditis. Chest radiograph findings in patients with acute pericarditis are typically normal unless there is concomitant pleuropulmonary disease or a very large pericardial effusion (>300 mL).

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Figure 4.
Cardiac Magnetic Resonance Images From a Patient With Acute Pericarditis

Findings characteristic of acute pericarditis that may be observed with cardiac magnetic resonance (CMR) imaging include pericardial thickening and evidence of pericardial edema. A, T1-weighted 4-chamber view showing thickened pericardium (yellow arrowhead). B, STIR T2-weighted 4-chamber view showing a pericardial hyperintense signal (yellow arrowhead) that indicates pericardial edema and left pleural effusion (black arrowhead). C, Late gadolinium enhancement 4-chamber view showing late enhancement of the pericardium (yellow arrowhead). Late gadolinium enhancement may persist beyond the acute phase of pericarditis indicating organizing pericarditis (chronic inflammatory pericarditis and fibrosis). D, Real-time free-breathing cine images, midventricular short-axis views, in expiration (left) and inspiration (right) showing septal flattening during inspiration (blue arrowhead), indicating accentuated ventricular interdependence. Images courtesy of Patrizia Pedrotti, MD, Giuseppina Quattrocchi, MD, and Alberto Roghi, MD, Ospedale Niguarda, Milan, Italy.

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