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Acute pericarditis

Definition
Acute pericarditis is a disease characterized by acute inflammation of the pericardium.
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Pathophysiology
Most cases of acute pericarditis are idiopathic (80-90%) and assumed to be due to viral infection. Other important causes include post-cardiac injury syndromes, connective tissue diseases (such as SLE), and cancer.
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Epidemiology
In the US, the incidence of acute pericarditis requiring hospitalization is estimated at 26 cases per 100,000 person-years.
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Disease course
Inflammation of the pericardium results in the formation of a pericardial effusion, which may progress to cardiac tamponade and obstructive shock.
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Prognosis and risk of recurrence
Acute pericarditis is associated with 5.7% all-cause mortality at 30 days, and 17.3% all-cause mortality at 1 year.
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Key sources
The following summarized guidelines for the evaluation and management of acute pericarditis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC/ESTRO/EHA/IC-OS 2022), the European Society for Microbiology and Infectious Diseases (ESCMID 2022), the Society of Cardiovascular Computed Tomography (SCCT/SCMR/AHA/SAEM/ASE/ACC/ACCP 2021), the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the Single Hub and Access Point for Pediatric Rheumatology in Europe (SHARE initiative 2019), the Pan-American League of Associations of Rheumatology (PANLAR 2018), the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ERN ReCONNET 2018), the Brazilian Society of Cardiology (BSC/ASE 2018), the American Heart Association (AHA/ASA 2018), the European Society of Cardiology (ESC/EACTS 2015), the Wilderness Medical Society (WMS 2014), and the American Heart Association (AHA/ACC 2013).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria: make a clinical diagnosis of acute pericarditis in patients with ≥ 2 out of 4 suggestive clinical criteria (chest pain, pericardial rub, ECG changes, and pericardial effusion).
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2.Diagnostic investigations

Initial evaluation: assess for independent predictors of an identifiable and specifically treatable cause of pericarditis (such as bacterial, neoplastic, or systemic inflammatory diseases).
B
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  • Transthoracic echocardiography

  • Cardiac MRI/CT

  • Evaluation for viral pericarditis

3.Diagnostic procedures

Coronary angiography: perform coronary angiography (according to clinical presentation and risk factor assessment) to rule out acute coronary syndromes in patients with pericarditis and suspected myocarditis.
B

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  • Diagnostic pericardiocentesis

  • Pericardial biopsy

4.Medical management

Setting of care
Offer outpatient management in low-risk patients with acute pericarditis.
B
Admit high-risk patients with acute pericarditis to the hospital.
B
Admit patients with myocardial involvement to the hospital for diagnosis and monitoring.
B

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  • NSAIDs

  • Colchicine

  • Corticosteroids

  • Management of recurrent pericarditis

5.Nonpharmacologic interventions

Exercise restriction, simple pericarditis
Consider advising exercise restriction until resolution of symptoms and normalization of CRP, ECG, and echocardiogram in non-athletes with acute pericarditis.
C
Consider advising exercise restriction for at least 3 months and until resolution of symptoms and normalization of CRP, ECG, and echocardiogram in athletes with acute pericarditis.
C

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  • Exercise restriction (myopericarditis)

6.Specific circumstances

Pediatric patients: administer NSAIDs at high doses as first-line therapy for acute pericarditis in pediatric patients until complete symptom resolution.
B
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  • Patients with purulent pericarditis

  • Patients with uremic pericarditis

  • Patients with post-cardiac injury syndromes

  • Patients with radiation pericarditis

  • Patients chemotherapy-induced pericarditis

  • Patients with neoplastic pericardial disease

  • Patients with SLE

  • Patients with relapsing polychondritis

  • Patients with polyarteritis nodosa

  • Patients with Lyme disease

  • Patients with Chagas disease

  • Patients with lightning injury

  • Patients with long COVID

  • Patients with AIS

7.Follow-up and surveillance

Follow-up
Schedule follow-up 1 week after treatment initiation to assess response to anti-inflammatory therapy.
B
Consider obtaining echocardiography every 6-12 months after post-cardiac injury pericarditis to exclude possible evolution toward constrictive pericarditis.
C