You are reviewing a 42-year-old man in the outpatient clinic who is under follow-up for recurrent troublesome attacks of acute pericarditis. He has had 16 episodes of pericarditis which initially followed a viral illness. No underlying systemic cause has been found despite extensive investigations. The episodes are associated with small- to moderate-sized pericardial effusions. Initially, the episodes respond well to systemic steroids; however, he has troublesome steroid side effects. On weaning the steroids with appropriate colchicine cover, the episodes recur.
What is the best option with regard to management?
This is a case of idiopathic pericarditis with characteristic recurrences on steroid withdrawal. Surgical pericardiectomy has been shown to alleviate the disorder and should be considered in cases of troublesome recurrent disease. There is a risk of failure to resolve symptoms if there is residual pericardial tissue postoperatively. In addition, recurrent disease can occur in the visceral pericardium, which cannot be stripped surgically.
A 62-year-old man is admitted with chronic obstructive pulmonary disease (COPD) and mild left ventricular (LV) dysfunction (ejection fraction [EF] 45%) as well as symptomatic, recurrent atrial fibrillation (heart rate [HR] 120s to 150s) despite antiarrhythmic drug therapy and direct current cardioversion in the past. After rate control with intravenous (IV) βblockers, the HR improves and the patient feels better. Given his recurrent atrial fibrillation despite optimal medical therapy, the patient is referred for radiofrequency ablation of atrial fibrillation (pulmonary vein isolation) procedure. The procedure is performed on anticoagulation (international normalized ratio >2.0) and is deemed a success, with no inducible atrial fibrillation at the end of the case. A small atrial septal defect (ASD) was noted with intracardiac echocardiography at the end of the case, with no other remarkable findings. That evening in the post-anesthesia care-unit (PACU), the patient is noted to be hypotensive and tachycardic with increasing dyspnea. There is a concern for cardiac tamponade; however, the arterial line does not show a significant respiratory variation of the blood pressure (BP) waveform (pulsus paradoxus). An echocardiogram is performed, demonstrating a large circumferential effusion and the patient is referred for urgent pericardiocentesis.
Which of the following explains why the patient did not develop a pulsus on the arterial line, despite a large, hemodynamically significant pericardial effusion?
Presence of an ASD. The presence of the iatrogenic ASD after the transseptal puncture for the radiofrequency ablation/pulmonary vein isolation procedure equates right atrial (RA) and left atrial (LA) pressures with inspiration. The predicted decrease in LV filling during inspiration due to interventricular dependence and exaggerated RV filling and septal shift toward the LV is mitigated by the presence of an ASD. With inspiration, the decrease in intrathoracic pressure is transmitted to both atria and thus preload to the LV is maintained and interventricular dependence is not as pronounced. Thus, the variation in systolic blood pressure is not as prominent, resulting in minimal to no pulsus paradoxus. Administration of excess fluid would stave off circulatory collapse in tamponade; however, it would not diminish the pulsus. Answer b is incorrect as with severe LV dysfunction, patients can have a pulsus alternans (variation in peak systolic pressure with every other beat) and Answer c is incorrect as obstructive lung disease can lead to the presence of a pulsus due to exaggerated inspiratory effort and negative intrathoracic pressure.
A 38-year-old patient with no prior medical history presents to the emergency room with 4 days of chest discomfort. He denies any recent trauma, fever, or use of anticoagulants. The pain is positional and the patient reports mild upper respiratory infection (URI) symptoms in the preceding week. Laboratory work is notable for elevated white blood cell count (neutrophil predominance) as well as elevated erythrocyte sedimentation rate (ESR)/high-sensitivity C-reactive protein (hsCRP); his troponin and other laboratory work is otherwise negative/normal. Electrocardiogram (ECG) is consistent with pericarditis. There is a low suspicion for acute coronary syndrome, and acute pericarditis is diagnosed with small effusion on the echocardiogram; the pain improves with analgesics.
Which of the following regimens is the most appropriate therapy for this patient to treat the acute episode and maintain remission?
Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months. The patient presents with an initial attack of acute pericarditis without any high-risk features (small effusion, negative troponin, no fever/trauma, or anticoagulant use). The appropriate regimen in this case would be an NSAID (ibuprofen 600 to 800 mg TID or indomethacin 50 mg TID) for a course of 1 to 2 weeks with physician follow-up. In addition, the use of colchicine has been studied in two trials with improvement in symptom resolution and maintenance of remission at a dose of 0.5 mg (daily for <70 kg; BID for >70 kg) for a fixed period of 3 months.
Aspirin and colchicine can be used together; however, the dosing is incorrect for Answer b (650 to 1,000 mg TID) and the colchicine should still be continued for 3 months. Prophylactic Proton-pump inhibitor (PPI) should be utilized during the high-dose NSAID use to prevent gastric ulcer. Answer c is incorrect (dosing of ibuprofen is incorrect). Answer d is incorrect since steroid therapy is only reserved for patients with NSAID or acetylsalicylic acid (ASA) contraindication or patients having relapsing pericarditis that is refractory to NSAID/ASA therapy.
A 62-year-old man with cardiac risk factors of tobacco use, hypertension, and diabetes mellitus returns for follow-up after late-presenting mid-left anterior descending artery (LAD) ST-elevation myocardial infarction (MI). He had an occluded mid-LAD, which was successfully aspirated and stented with a single drug-eluting stent; no significant disease elsewhere is noted. The next day he reports progressive chest discomfort and mild fever and has developed a two-component pericardial friction rub on physical examination. His ECG is concerning for pericarditis (Dressler syndrome) and an echo is performed showing no interval change from discharge other than the presence of a small pericardial effusion.
Which of the following regimens would be the most appropriate therapy in this patient?
Aspirin 650 TID for 2 weeks with taper to 81 mg daily + colchicine 0.5 mg BID for 3 months. The patient has postinfarction pericarditis with a typical presentation after reperfusion for late-presenting MI. Although not as frequent, postinfarction pericarditis (Dressler syndrome) is still seen in a small percentage of patients after large MI, and cardiac/pericardial trauma. The regimen used in these patients is modified to include aspirin (instead of NSAIDs) for two reasons: (a) aspirin is required for patients with CAD, with or without recent stenting; and (b) NSAIDs are postulated to impair scar formation and wound healing after an MI. Colchicine is still part of the regimen despite the recent MI and helps with symptom resolution. Correct answer is a—with high-dose aspirin initially with gradual taper once symptoms improve. The clopidogrel is continued despite high doses of aspirin, due to the placement of a recent intracoronary stent.
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?
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.
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