Cardiology>>>>>Pulmonary Hypertension And Pericardium
Question 15#

A 45-year-old male patient with a history of acute pericarditis now returns for outpatient follow-up with increasing dyspnea and lower extremity edema. The patient was seen and started on high-dose aspirin and colchicine (no nonsteroidal anti-inflammatory drugs [NSAIDs] due to allergy) and has not been able to taper for the past 6 months due to persistent low-level symptoms. He has an elevated jugular venous pulse without inspiratory decline, 2+ pedal edema, and congested liver without ascites, as well as a soft pericardial knock. Laboratory values are notable for mild transaminitis as well as elevated ESR/hsCRP. ECG is unremarkable and echo shows a small persistent pericardial effusion with tubular-shaped LV with normal function, along with diastolic bounce and conical-shaped right ventricle (RV) as well as plethoric inferior vena cava and respirophasic transmitral and trans-tricuspid variation all consistent with constrictive pericarditis.

Which of the following would be the next most appropriate step in management?

a. Initiate steroid therapy (0.25 to 0.5 mg/kg/day) along with colchicine, and initiate PO diuretic
b. Admit for IV diuresis and transition to PO diuretic regimen after cardiac catheterization for constriction evaluation
c. Repeat echo in 2 to 3 months aspirin and colchicine at current doses
d. Surgical evaluation for pericardiectomy/stripping

Correct Answer is A

Comment:

Initiate steroid therapy (0.25 to 0.5 mg/kg/day) along with colchicine, and initiate PO diuretic. The patient had acute pericarditis, which transformed into a chronic effusive constrictive pericarditis. There is evidence of therapy failure (persistent symptoms and elevated biomarkers) and ongoing inflammation, leading to symptomatic constrictive pericarditis with increasing hemodynamic significance (as demonstrated by symptoms/physical examination and echo findings). The next step would be to escalate anti-inflammatory therapy to include glucocorticoids (prednisone) to help abate the ongoing symptoms and pericardial inflammation. Glucocorticoids are generally not first-line therapy since patients who receive them early in the course of the disease process are more likely to have relapsing pericarditis and eventually develop constrictive pericarditis. In the case of this patient, he does not have any other treatment options due to his NSAID allergy, so steroids should be initiated at a low dose and maintained with very gradual taper (weeks to months) that involves assessment of his symptoms, biomarker trend (ESR/hsCRP), as well as MRI findings to assess for inflammation/edema within the pericardium to help quell the disease process. 

Admission for IV diuresis is not necessary as the patient has not proven resistance to PO diuretics and although a cardiac catheterization may be required alternative noninvasive diagnostic modalities should be performed prior to catheterization to make the diagnosis. Answer c is incorrect since the patient has demonstrated treatment failure with progression of symptoms in the interim. Answer d is incorrect as medical therapy options (steroids, diuresis) are still available. Pericardiectomy is generally reserved in medically refractory cases.