Acute and recurrent pericarditis

Abstract

Viral and idiopathic pericarditis are the most common forms of pericarditis encountered in clinical practice in developed countries with a low prevalence of tuberculosis. The course of these cases is relatively benign and self-limiting, the most common complication being recurrence. The mainstay of therapy is empiric anti-inflammatory therapy with aspirin or a non-steroidal anti-inflammatory drug (NSAID) plus colchicine. Specific features at presentation may suggest the increased risk of complications during follow-up and non-viral aetiologies (e.g. high fever >38ºC (100.4ºF), subacute course with symptoms over several days without a clear-cut acute onset, evidence of large pericardial effusion with diastolic echo-free space >20 mm, cardiac tamponade, failure to respond within 7 days to aspirin/NSAID, associated myocarditis (myopericarditis), immunodepression, trauma, and oral anticoagulant therapy). The presence of one or more of these features identifies a potentially high-risk case of pericarditis to be admitted. In these cases an aetiology search is mandatory. Patients with pericarditis and no risk features can be considered at low risk and managed as outpatients. In these cases follow-up is mandatory after 1 week to assess the response to empiric anti-inflammatory therapy. Recurrent pericarditis is the most troublesome complication following acute pericarditis and occurs in 20–50% of patients. Most cases of recurrent pericarditis are idiopathic and the pathogenesis is presumed to be immune mediated or autoinflammatory. The prognosis of idiopathic recurrent pericarditis is generally good with the risk of chronic evolution towards constrictive pericarditis related to the aetiology and not the number of recurrences.