Thanks to Alex, Ashley, and Arvind (AAA?) for presenting the case of a middle-aged man with recurrent pericarditis! We discussed a couple of cardiac procedures. We also discussed his macrocytic hypoproliferative anemia and thrombocytopenia with a pending bone marrow biopsy, but the pearls will focus on the cardiac elements of the case. Thanks ZSFG for having me as your guest today!
- Most pericarditis cases are idiopathic!
- Treatment of recurrent pericarditis is similar to treatment of the initial episode, with 1st line being NSAIDs + colchicine.
- Diagnostic yield of pericardiocentesis is relatively low (<40%)
For those interested in more info:
Acute and Recurrent Pericarditis
- Most cases are idiopathic! (presumed viral or immune-mediated)
- Infectious: Viral, TB, Bacterial, Fungal, Parasitic
- Autoimmune (SLE, RA, Sjogren, Scleroderma, MCD, vasculitis)
- Neoplastic (lung, breast, Hodgkin, leukemia, melanoma, paraneoplastic)
- Metabolic (Hypothyroid, Uremia)
- Post-Cardiac Injury
- For acute pericarditis, NSAID x 1-2 weeks + colchicine x 3 months. Preferred NSAIDs are ibuprofen or indomethacin. Aspirin may also be used. All are TID!
- Treatment of recurrent pericarditis is the same as acute! Except colchicine duration is extended to at least 6 months.
- For post-MI pericarditis, aspirin + colchicine is preferred. Recommended to avoid other NSAIDs and steroids in this setting.
- For refractory cases, contraindication to NSAID, or autoimmune etiology, regimen is prednisone + colchicine
- Adding colchicine reduces recurrence rate!
- Recurrent pericarditis occurs in 1/3 of patients with acute pericarditis
- Steroids may increase the risk of recurrence
- Pericardiectomy if chronic symptomatic constrictive pericarditis refractory to medical therapy
- Therapeutic for tamponade
- Suspicion for purulent, tuberculous, or neoplastic pericarditis
- Moderate to large pericardial effusions of unknown etiology that do not respond rapidly to anti-inflammatory therapy
- Diagnostic yield relatively low (<40%)
Endomyocardial biopsy (EMB)
- Main value is dx of uncommon myocardial disorders such as giant cell myocarditis, hypereosinophilia, sarcoidosis, and other cardiomyopathies/myocarditis
- Also useful for select cases of heart failure, dilated CM, and select cardiac tumors if other evaluation inconclusive
- Usually RV biopsy (venous approach), more rarely LV (arterial approach) due to risk of perforation and stroke
- Clinical diagnosis ultimately established in 50% of cases, but specific histologic diagnostic yield of EMB only 15% (mostly myocarditis and infiltrative disease)
Have a great day everyone!