What are the causes and treatment options for pericarditis?

Causes and Treatment of Pericarditis

The most common cause of pericarditis is viral infection, followed by autoimmune conditions, bacterial infections (particularly tuberculosis in developing countries), post-cardiac injury syndromes, and neoplastic disease. 1

Etiology of Pericarditis

Infectious Causes

• Viral pericarditis: Most common form in developed countries, caused by enteroviruses (coxsackieviruses A and B, echoviruses), herpesviruses (EBV, CMV, HHV-6), parvovirus B19, influenza viruses, HIV, and others 1
• Bacterial pericarditis:
  • Tuberculous pericarditis: Most common form worldwide, especially in developing countries where it accounts for >90% of pericardial disease in HIV-infected individuals and 50-70% in non-HIV-infected individuals 1
  • Purulent pericarditis: Caused by Staphylococcus, Streptococcus, Haemophilus, and other bacteria; occurs through direct infection, spread from adjacent structures, or hematogenous dissemination 2
• Fungal pericarditis: Less common, often in immunocompromised patients 1

Non-Infectious Causes

• Autoimmune disorders: Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis 1, 3
• Post-cardiac injury syndromes: Following cardiac surgery, percutaneous coronary interventions, pacemaker insertion, catheter ablation 1
• Neoplastic pericarditis: Primary tumors or metastatic disease (lung, breast cancer, lymphoma, leukemia) 1
• Metabolic disorders: Uremia, myxedema 1
• Trauma: Direct injury to the pericardium 4
• Radiation-induced: Following radiation therapy, especially for Hodgkin's disease or breast cancer 1
• Drug-induced: Various medications can trigger pericardial inflammation 1

Treatment of Pericarditis

Acute Pericarditis Treatment

1. First-line therapy:

   • NSAIDs: Aspirin (500-1000 mg every 6-8 hours) or ibuprofen (600 mg every 8 hours) with gastroprotection 1
   • Colchicine: Added to NSAIDs (0.5 mg twice daily if ≥70 kg or 0.5 mg once daily if <70 kg) for at least 3 months to improve response and prevent recurrences 1

2. Second-line therapy (for contraindications/failure of first-line therapy):

   • Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) when infectious causes have been excluded 1
   • Corticosteroids should NOT be used as first-line therapy as they may increase risk of recurrence 1

3. Specific etiological treatment:

   • Bacterial pericarditis: Urgent drainage combined with appropriate antibiotics (e.g., vancomycin, ceftriaxone, ciprofloxacin) 2
   • Tuberculous pericarditis: Anti-tuberculosis drugs (isoniazid, rifampin, pyrazinamide, ethambutol) for at least 6 months 2
   • Viral pericarditis: Generally self-limiting; some experts suggest specific antiviral treatments in severe cases, though evidence is limited 1

Recurrent Pericarditis Treatment

1. First-line therapy:

   • NSAIDs and colchicine: Same as for acute pericarditis but for longer duration (≥6 months) 1

2. Second-line therapy:

   • Low to moderate dose corticosteroids: Added to NSAIDs and colchicine as triple therapy, not as replacement 1
   • Slow tapering of corticosteroids is essential to prevent recurrence 1

3. Third-line therapy (for refractory cases):

   • Immunosuppressive agents: For cases not responding to conventional therapy 3

Complications and Prognosis

• Cardiac tamponade: More common with specific etiologies (malignancy, tuberculosis, purulent pericarditis) 1, 4
• Constrictive pericarditis: Risk varies by etiology - low (<1%) for viral/idiopathic, intermediate (2-5%) for autoimmune/neoplastic, high (20-30%) for bacterial causes 1
• Recurrence: Occurs in 15-30% of patients after initial episode; risk increases to 50% after first recurrence if not treated with colchicine 1

Important Clinical Considerations

• Comprehensive diagnostic workup is essential for identifying specific causes, especially in cases with high-risk features (fever >38°C, subacute onset, large effusion, tamponade) 1
• Exercise restriction is recommended until resolution of symptoms and normalization of inflammatory markers, ECG, and echocardiogram 1
• For athletes, exercise restriction should continue for at least 3 months 1
• Corticosteroids should be avoided in suspected viral pericarditis as they may reactivate viral infections 1