- The document discusses three cases of patients presenting with chest pain and suspected pericarditis. - For the first patient, the doctor would not diagnose recurrent pericarditis and would reassure the patient, treating pain with Tylenol or NSAIDs as needed. - The second patient is likely recurrent pericarditis given prior treatment failure, and would be treated with ibuprofen and colchicine for 3-6 months with follow up ECG. - The third patient has complex medical history of rheumatoid arthritis treated with steroids previously. NSAID and colchicine would be tried initially but steroids may be needed if pain persists after 1 month. Failure of

1. A Frustrating Disease in
Cardiology
Cases and Treatment Options

2. Case 1
 53 y F with 3/12 CP typical to pericarditis attack
6/12 ago that was treated with ASA only for 14
days with complete recovery.
 Normal physical exam no rub
 Normal WBC and ESR
 Normal ECG
 ECHO: no PE

3. Does she have recurrent
pericarditis?
How would you treat her?

4. Case 2
 48 y M with with 1 attack of pericarditis
4/12(treated with ASA with no good
response ) ,came with SOB and extensional CP
similar to his previous attack.
 V/S stable no rub
 ECHO : 0.7 cm effusion
 WBC 14 , CK and trop –ve.

5. ECG

6. How would you treat him ?

7. Case 3
 68 y M with RA. Referred by GP with CP
(pericarditis).
 Required multible steroid courses for RA.
 On going similar pain for 6/12 treated by his
rheumatologist with steroid( 40 mg for 14 days).
 v/s stable no rub
 ECG non specific T changes
 ESR 82.
 ECHO : diastolic dysfunction with 1 cm PE with no
increase in ICP

8. How would you treat him ?

9. Recurrent Pericarditis
Objectives
 How to make the diagnosis?
 How is at risk?
 Prognosis
 Treatment options
 Guideline

10. Definition
 Need 1 + 2 + any of 3
1) A documented first attack of acute pericarditis
2) Recurrent pain
3) Fever
Friction rub
ECG changes
Pericardial effusion
Elevation WBC or ESR or CRP

11. Etiology
Heart 2004;90;1364-1368

12. Causes of recurrence …
 (i) insufficient dose or treatment duration of the
previous attack.
 (ii) early corticosteroid treatment causing
augmented viral DNA/RNA replication in the
pericardial tissue leading to increased viral
antigen exposure.
 (iii) exacerbation of an underlying connective
tissue disease .

13. Work up …
 Often negative
 Not recommended to consider routine
pericardial tap for diagnostic purpose
 Work up for infectious and or CT causes are
guided by clinical picture
Mayo Clin Proc 2002 Jan;77(1):39-43
Am J Cardiol. 2006 Jul 15;98(2):267-71
Am J Cardiol 2005 Sep 1;96(5):736-9

14. Course and types
 The first symptoms of recurrent pericarditis occur at a
variable time after the initial attack, but usually within
18 to 20 months.
1)The intermittent form, symptoms start after a symptom-
free interval longer than six weeks after drug
withdrawal .
2)The incessant form, symptoms appear within six weeks
after drug discontinuation or during attempted
weaning.

15. Symptoms
 The most frequent symptom of recurrent
pericarditis is chest pain.
 Typically sharp improve with sitting
 Mimic angina (exertional) once chronic .

16. Answer this ..
 ………. is the most common cause of SOB in patients
with recurrent pericarditis .
 A) Tamponade
 B) Constrictive pericarditis
 C) All of above
 D) Non of the above
Answer is D

17. Complications
 31 patients , follow up for 2-19y :
 3 patients had Tamponade initially
 None during recurrence
 No constriction
J Am Coll Cardiol 1986 Feb;7(2):300-5

18. Complications
221 patients , 5 years f/u
15 patients , 8 years f/u
J Am Coll Cardiol. 2003 Aug 20;42(4):759-64. JACC Vol. 43, No. 6, 2004 March 17, 2004:1042–6

19. Prognosis
 Prognosis is excellent for most patients with
idiopathic recurrent pericarditis.
 Severe complications are uncommon even with
multiple recurrences
 Not associated with myocardial systolic or
diastolic dysfunction
 Rarely associated with constriction .
 Quality of life can be severely affected
Mayo Clin Proc 2002 Jan;77(1):39-43
Am J Cardiol. 2006 Jul 15;98(2):267-71
Am J Cardiol 2005 Sep 1;96(5):736-9

20. What predicts recurrence ?

21. Predictors of recurrence
 No presenting clinical feature of an initial
episode of acute pericarditis reliably predicts
recurrence.
 The response to therapy and type of therapy for
the initial episode may have some prognostic
value.

22. 1) Failure of NSAID
254 patients , 5 years f/u
J Am Coll Cardiol 2004 Mar 17;43(6):1042-6.

23. 2) Steroid therapy
294 patients , 5 years f/u
Am J Cardiol 2005 Sep 1;96(5):736-9.

24. Steroid therapy
120 patients , 4 years f/u
Circulation 2005 Sep 27;112(13):2012-6.

25. Therapy

26. Before that…
 Recurrent pericarditis can be a prolonged and
frustrating disease to patients and doctors.
 Because of this and the need to maintain
compliance, effective communication with the
patient is important.

27. Things to keep in mind…
 Further recurrences are possible
 Not always the same etiology
 Good prognosis
 The possibility of pericardiectomy
 Complications of immunosuppressant
 Out patient therapy

28. What is recommended…

29. Colchicine plus NSAID

30. COPE
Circulation 2005 Sep 27;112(13):2012-6.

31. 48 patients, 4 years f/u
CORE
Am J Cardiol. 2005 Sep 1;96(5):736-9

32. Recommended dose for Colchicine
 > 70 kg 2 mg/day for 1-2 days, followed dose of
1 mg/day for 6/12 plus NSAID and at least for
3/12.
 < 70 kg 1 mg/day for 1-2 days followed by 0.5
mg/daily for 6/12 plus NSAID at least for
3/12.
 Bone marrow suppression, hepatotoxicity,
muscle and kidney toxicity

33. NSAID
 The patient's prior experience can provide a
useful guide.
 If a patient reports that a specific NSAID drug
has proven effective, it is reasonable to use that
agent.
 This approach should be maintained until it is
clear that NSAIDs have failed to control the
syndrome, especially the pain, or that the drugs
are not tolerated.

34. Recommended NSAID
 Ibuprofen 800 mg four times daily then 600 mg
four times daily at two weeks and to 400 mg
four times daily at four weeks.
 ASA 2.0 to 4.0 g/day in divided doses for
patients with CAD.
 Treatment is discontinued after 3/12. Slow
tapering is recommended in an attempt to
reduce the subsequent recurrence rate.
 Prophylactic PPI

35. Steroids are not bad…but
 Glucocorticoid therapy should generally be
avoided in patients with recurrent pericarditis
 May be required to treat patients who fail
NSAID and/or colchicine therapy.
 Common mistakes are to use too low dose and,
more often, to taper the dose too rapidly

36. High vs. low steroid dose
and duration
12 patients
J Am Coll Cardiol 2005 Nov 1;26(5):1276-9.

37. Tapering the dose
 Prednisone 1-1.5/kg/day is the ideal .
 Tapered 10 mg/day every one to two weeks
for total of 3/12
 Each decrement in steroid dose should proceed
only if the patient is asymptomatic and C-
reactive protein is normal.

38.  Toward the end of the taper, NSAID or
colchicine should be introduced to complete 3-
6/12 if needed.
 If symptoms recur every effort should be made
not to increase or reinstitute corticosteroids, but
instead control symptoms with NSAID.
 Osteoporosis prevention

39. Immunosuppressant
 The ESC guidelines recommend azathioprine
(75 to 100 mg/day).
 Methotrexate
 Cyclophosphamide
 IG

40. Intrapericardial therapy
260 patients
15 patients
Eur Heart J 2002 Oct;23(19):1503-8

41. Pericardiectomy
 Still a treatment option for refractory cases
or its complication Constriction
 Operators dependent with high mortality rate .

42. Recurrent pain without objective
evidence of disease

43.  A difficult management .
 This problem is most likely to occur in more
chronic cases in which numerous recurrences
have been suppressed by steroid.
 Pain management should be initiated
 Pain management begins with Tylenol
 Pain service
 Watch for recurrence.

44. Case 1
 53 y F with 3/12 CP typical to pericarditis attack
6/12 ago that was treated with ASA only for 14
days with complete recovery.
 Normal physical exam no rub
 Normal WBC and ESR
 Normal ECG
 ECHO: no PE

45. Does she have recurrent
pericarditis?
How would you treat her?

46.  NO
 Reassurance
 Tylenol and NSAID as needed
 Pain service
 Follow up with GP keeping in mind referral to
cardiology for more objective findings .

47. Case 2
 48 y M with with 1 attack of pericarditis
4/12(treated with ASA with no good
response ) ,came with SOB and extensional CP
similar to his previous attack.
 V/S stable no rub
 ECHO : 0.7 cm effusion
 WBC 14 , CK and trop –ve.

48. How would you treat him ?

49.  Ibuprfen despite ASA failure and colchicine
course for 3-6/12.
 Follow up

50. ECG 3 weeks

51. Case 3
 68 y M with RA. Referred by GP with CP
(pericarditis).
 Required multible steroid courses for RA.
 On going similar pain for 6/12 treated by his
rheumatologist with steroid( 40 mg for 14 days).
 v/s stable no rub
 ECG non specific T changes
 ESR 82.
 ECHO : diastolic dysfunction with 1 cm PE with no
increase in ICP

52. How would you treat him ?
What predicts recurrence ?

53.  NSAID and colchicine for 3-6/12
 No steroid after talking to rheumatologist .
 After 1/12 pain got wore despite ASA and
colchicine .
 Switched to prednisone 70mg/day tapered
slowly over 3/12 .

54. Thanks