The Correct Answer is A!

 

A 42-year-old man presents for evaluation of his fourth episode of acute pericarditis manifested by severe pleuritic chest pain improved with learning forward and pericardial rub on the cardiac exam. Each of his previous episodes has responded to nonsteroidal anti-inflammatory drugs (indomethacin 25 mg by mouth four times daily for up to four weeks), but he develops recurrence shortly after cessation.

Which of the following is the best next step?

A) Indomethacin plus colchicine

B) Prednisone

C) Prednisone plus indomethacin

D) Pericardiectomy

Rationale:

Recurrent pericarditis occurs at a rate of 15%-30% after an initial episode. A recurrence is diagnosed by evidence of subsequent pericarditis after a documented first episode of acute pericarditis and at least 4-6 week symptom-free interval. Diagnosis of a recurrent episode is the same as that of acute pericarditis and must include two of the following: chest pain, presence of a pericardial friction rub, ECG changes (diffuse ST elevation of PR depression), and pericardial effusion.

The treatment approach to recurrent pericarditis should target the underlying etiology in patients that have an identified cause. However, NSAIDs or aspirin remain the mainstay of treatment. Also, colchicine should be added without a loading dose and using weight-adjusted doses (0.5 mg daily if body weight <70 kg, or 0.5 mg bid if body weight is ≥70 kg) for six months. Colchicine improves response to therapy, remission rates, and prevents recurrences. Corticosteroids can be added in low/moderate doses as part of triple therapy if there is incomplete response to NSAIDs/aspirin and colchicine, or they can be added earlier in cases of intolerance or contraindications to NSAIDs/aspirin or colchicine. Corticosteroids should be avoided in cases of pericarditis with infectious etiology.

A third line of treatments include immunomodulatory drugs such as azathioprine, IVIG, and anakinra. As a last resort, pericardiectomy can be performed when all medical therapies have failed.

ReferencesAdler Y, Charron P, Imazio M, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC) endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921-2964.

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