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C ase Presentation: A 56-year-old it cannot be attributed to a specific tuberculosis, neoplastic disease, uremia,
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previously healthy man presented condition.2,3 Because these 2 etiologies or collagen vascular disorders), hypo-
with 2 days of pleuritic left anterior are clinically equivalent, the term idio- tension, jugular venous distension, a
chest pain, lessened by sitting forward. pathic pericarditis will refer to both in large pericardial effusion, or echocar-
His examination was pertinent for low- this Clinician Update. Even when man- diographic features of impending tam-
grade fever (37.6°C), blood pressure aged effectively, many patients with ponade (Figure).5,6 Patients who are
122/76 mm Hg without paradox, no acute pericarditis present with 1 or immunocompromised or are undergoing
jugular venous distension, clear lungs, more repeated episodes, termed recur- therapy with anticoagulants should also
and a 3-component pericardial friction rent pericarditis.4 be observed initially in the hospital.5
rub. The ECG showed diffuse concave-
upward ST-segment elevation and Acute Pericarditis Pharmacological Treatment
PR-segment depression in the inferior Management Effective agents include nonsteroidal
leads. The serum C-reactive protein level Treatment of idiopathic pericarditis anti-inflammatory drugs (NSAIDs),
was 64 mg/L, and the cardiac troponin has long been empirical, because until colchicine, and glucocorticoids. Con-
T was not elevated. Echocardiography recently, there have been few therapeu- currently, rest and avoidance of demand-
showed normal left ventricular contrac- tic trials addressing this condition. The ing physical activity help to minimize
tile function without wall motion abnor- European Society of Cardiology pub- symptoms.
malities and no pericardial effusion. He lished the only treatment guideline for Nonsteroidal Anti-inflammatory
was diagnosed with acute pericarditis, pericarditis almost a decade ago, and Drugs
and the symptoms responded promptly many of the recommendations were Aspirin and other NSAIDs are the
to oral ibuprofen, continued for 2 weeks. based on opinion because of the lack of first-line approach, based on clinical
Six weeks later, he redeveloped pleuritic available study evidence.4 experience and observational reports.5,7
chest pain and clinical and ECG findings Most patients with idiopathic peri- For example, in a 2004 study without
identical to the initial presentation. His carditis experience self-limited symp- a control group, outpatient therapy of
primary care physician asks for advice toms that improve spontaneously within uncomplicated pericarditis with aspi-
about appropriate therapy. days to weeks. More rapid relief can be rin relieved symptoms in 87% of 254
achieved with pharmacological interven- patients.5 Commonly used NSAID
Background tion, and stable patients can be managed regimens are listed in the Table, with
Pericarditis accounts for 5% of emer- in the outpatient setting. Hospitalization a recommended initial duration of 7
gency department visits for chest pain is recommended when features suggest to 14 days, then treatment should be
in the absence of myocardial infarc- nonidiopathic causes or herald hemo- tapered until resolution of symptoms
tion.1 In ≈80% of cases in developed dynamic compromise, including fever and improvement of acutely elevated
countries, the cause of pericarditis is >38°C (>100.4°F), the subacute devel- serum inflammatory markers such as
either postviral or “idiopathic,” in that opment of symptoms (characteristic of C-reactive protein and the erythrocyte
From the Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.
Correspondence to Leonard S. Lilly, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail
llilly@partners.org
(Circulation. 2013;127:1723-1726.)
© 2013 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.111.066365
1723
1724 Circulation April 23, 2013
use, osteoporosis prevention (eg, cal- parenteral NSAID ketorolac may be PR, Torp-Pedersen C, Gislason GH. Long-
term cardiovascular risk of nonsteroidal
cium, vitamin D, and bisphosphonates) beneficial. For recurrent episodes of
anti-inflammatory drug use according to time
should be considered. pericarditis, treatment with an NSAID passed after first-time myocardial infarc-
A common cause of referral to plus colchicine is recommended, but tion: a nationwide cohort study. Circulation.
specialized pericardial centers is the for a more prolonged course. During 2012;126:1955–1963.
11. Adler Y, Finkelstein Y, Guindo J, Rodriguez
inability to taper glucocorticoid ther- NSAID treatment, concurrent gastric de la Serna A, Shoenfeld Y, Bayes-Genis A,
apy below a certain dosage (typically protection therapy should be consid- Sagie A, Bayes de Luna A, Spodick DH.
≈15 mg of prednisone daily) without ered. Only for truly refractory cases Colchicine treatment for recurrent pericar-
ditis: a decade of experience. Circulation.
reemergence of symptoms, despite should glucocorticoid therapy be used. 1998;97:2183–2185.
concurrent NSAID plus colchicine 12. Imazio M, Bobbio M, Cecchi E, Demarie D,
treatment. An often effective strategy Disclosures Demichelis B, Pomari F, Moratti M, Gaschino
in this circumstance is to resume the G, Giammaria M, Ghisio A, Belli R, Trinche-
None.
ro R. Colchicine in addition to conventional
lowest prior steroid dosage that had therapy for acute pericarditis: results of the
controlled symptoms, and then taper it References COlchicine for acute PEricarditis (COPE)
by only 1 to 2 mg every 2 to 4 weeks.19 1. Khandaker MH, Espinosa RE, Nishimura
trial. Circulation. 2005;112:2012–2016.
13. Lotrionte M, Biondi-Zoccai G, Imazio M,
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Circulation. 2013;127:1723-1726
doi: 10.1161/CIRCULATIONAHA.111.066365
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