Pericardial Disease

The answer first

Pericardial disease is a family of syndromes that share the pericardium as their target organ but behave very differently. The four syndromes you must hold in mind are acute pericarditis, pericardial effusion with or without cardiac tamponade, constrictive pericarditis, and recurrent pericarditis. Each has a distinctive clinical fingerprint and a different urgency. [1]

The three management decisions that examiners test again and again: [1]

1. Acute viral pericarditis is treated with NSAIDs plus colchicine — not steroids. Steroids increase recurrence risk and are reserved for NSAID failure, autoimmune disease, or uraemic pericarditis.
2. Cardiac tamponade is a clinical diagnosis confirmed by echo, and the treatment is emergency pericardiocentesis — not fluid, not pressors, not waiting for the next set of bloods.
3. Constrictive pericarditis presents as right heart failure with a raised JVP showing prominent X and Y descents and a pericardial knock, and the definitive treatment is pericardiectomy — but first you must distinguish it from restrictive cardiomyopathy. [1]

DWE high-yield: If a stem describes a young adult with sharp pleuritic chest pain that improves on sitting forward, plus diffuse ST elevation and PR depression on ECG, the answer is acute pericarditis — treat with ibuprofen or aspirin plus colchicine. Steroids are a distractor. [1]

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1. [1]Adler 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.PMID 26320112
2. [2]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
3. [3]Brucato A, Imazio M, Gattorno M, et al. Effect of Anakinra on Recurrent Pericarditis Among Patients With Colchicine Resistance and Corticosteroid Dependence: The AIRTRIP Randomized Clinical Trial JAMA, 2016.PMID 27825009
4. [4]Imazio M, Belli R, Brucato A, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial Lancet, 2014.PMID 24694983
5. [5]Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review J Am Coll Cardiol, 2020.PMID 31918837
6. [6]Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial Circulation, 2005.PMID 16186437