Treatment of Acute and Recurrent Idiopathic Pericarditis

Abstract

Case Presentation: A 56-year-old previously healthy man presented with 2 days of pleuritic left anterior chest pain, lessened by sitting forward. His examination was pertinent for low-grade fever (37.6°C), blood pressure 122/76 mm Hg without paradox, no jugular venous distension, clear lungs, and a 3-component pericardial friction rub. The ECG showed diffuse concave-upward ST-segment elevation and PR-segment depression in the inferior leads. The serum C-reactive protein level was 64 mg/L, and the cardiac troponin T was not elevated. Echocardiography showed normal left ventricular contractile function without wall motion abnormalities and no pericardial effusion. He was diagnosed with acute pericarditis, and the symptoms responded promptly to oral ibuprofen, continued for 2 weeks. Six weeks later, he redeveloped pleuritic chest pain and clinical and ECG findings identical to the initial presentation. His primary care physician asks for advice about appropriate therapy. Pericarditis accounts for 5% of emergency department visits for chest pain in the absence of myocardial infarction.1 In ≈80% of cases in developed countries, the cause of pericarditis is either postviral or “idiopathic,” in that it cannot be attributed to a specific condition.2,3 Because these 2 etiologies are clinically equivalent, the term idiopathic pericarditis will refer to both in this Clinician Update. Even when managed effectively, many patients with acute pericarditis present with 1 or more repeated episodes, termed recurrent pericarditis .4 Treatment of idiopathic pericarditis has long been empirical, because until recently, there have been few therapeutic trials addressing this condition. The European Society of Cardiology published the only treatment guideline for pericarditis almost a decade ago, and many of the recommendations were based on opinion because of the lack of available study evidence.4 Most patients with idiopathic pericarditis experience self-limited symptoms that improve spontaneously within days to weeks. More rapid relief can be …