Pericarditis/Myopericarditis/Pericardial Effusion: A Contemporary Approach to Diagnosis and Management

Pericarditis is a common disease caused by various factors such as viral infections, systemic diseases, or drugs. A diagnosis of pericarditis is rendered in up to 5% of Emergency Room (ER) visits for non-ischemic chest pain. It is diagnosed when pleuritic chest pain is present, accentuated in the supine position, accompanied by ECG changes comprising new extensive ST-segment elevation and PR depression, a pericardial friction rub, and new or increased pericardial effusion on echocardiography. In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by post-procedural (iatrogenic) pericarditis, radiation therapy, and cardiac surgery. Tuberculosis is the most common cause of pericarditis in endemic areas and is managed with antituberculosis therapy, with corticosteroids used when there is concurrent constrictive pericarditis. New diagnostic techniques have aided the sampling and analysis of pericardial fluid and in determining its cause. Treatment of pericarditis comprises high-dose Non-Steroidal AntiInflammatory Drugs (NSAIDs) for uncomplicated cases, with doses tapered when symptoms have subsided and C-reactive protein level has normalized, typically over several weeks. Colchicine (often a 3-6-month course) is needed to both alleviate symptoms and decrease recurrences, while glucocorticoids and newer therapies with interleukin-1 blockers are reserved for recurrences and/or failures of prior therapies. Integrated use of new imaging methods facilitates more precise detection and better management of complications such as pericardial effusion or constriction. The diagnostic yield of extensive laboratory evaluation and pericardiocentesis remains low; hence, invasive procedures should be limited mostly to patients in whom a therapeutic intervention is needed. The majority of pericardial effusions can be safely drained with an echo-guided percutaneous technique. Pericardiectomy remains the definitive treatment for constrictive pericarditis and provides symptomatic relief in most cases. Importantly, differentiation of constrictive pericarditis from restrictive cardiomyopathy remains a clinical challenge, but is facilitated by tissue Doppler and colour M-mode echocardiography. All these issues are reviewed herein.