What is the management approach for a patient with Rheumatic Heart Disease (RHD) presenting with a pericardial rub?

Management of Pericardial Rub in Rheumatic Heart Disease

A pericardial rub in RHD indicates active pericardial inflammation requiring immediate anti-inflammatory therapy with NSAIDs or aspirin as first-line treatment, combined with colchicine, while simultaneously treating the underlying rheumatic activity with appropriate antibiotics and anti-inflammatory agents. 1

Initial Assessment and Risk Stratification

When a pericardial rub is detected in a patient with RHD, immediate evaluation is mandatory to determine the extent of pericardial involvement and exclude life-threatening complications 1:

• Perform ECG immediately to assess for typical pericarditis changes (widespread ST-elevation, PR depression) or evidence of myocardial involvement 1
• Obtain transthoracic echocardiography urgently to evaluate for pericardial effusion, assess effusion size, and rule out cardiac tamponade 1
• Measure inflammatory markers (CRP, ESR, white blood cell count) and cardiac biomarkers (troponin, CK) to gauge disease activity and detect myocardial involvement 1
• Obtain chest X-ray to assess cardiac silhouette and rule out pleural involvement 1

The presence of a pericardial rub is highly specific for pericardial inflammation, though it is transient and may disappear and reappear during the disease course 2, 3. In RHD patients, the rub indicates active rheumatic carditis affecting the pericardium.

Hospitalization Criteria

Admit patients with any of the following high-risk features 1, 4:

• Fever >38°C (100.4°F)
• Large pericardial effusion (diastolic echo-free space >20 mm)
• Evidence of cardiac tamponade
• Elevated troponin (indicating myopericarditis)
• Failure to respond to initial anti-inflammatory therapy after 1 week
• Immunosuppressed state

Anti-Inflammatory Treatment Protocol

First-Line Therapy

Initiate NSAIDs or aspirin as the cornerstone of treatment 1:

• Aspirin 1500-3000 mg/day divided every 8 hours, OR
• Ibuprofen 1200-2400 mg/day (600 mg every 8 hours) - preferred due to superior safety profile 1, 4
• Avoid indomethacin in elderly patients due to reduced coronary flow concerns 4

Add colchicine as adjunctive therapy 1:

• Colchicine 0.5 mg twice daily (if body weight ≥70 kg) or 0.5 mg once daily (if <70 kg)
• Continue for at least 3 months to reduce recurrence risk
• No loading dose required 1

Duration and Tapering

• Continue NSAIDs/aspirin for weeks to months until symptom resolution and CRP normalization 1
• Taper aspirin by 250-500 mg every 1-2 weeks 1
• Taper ibuprofen by 200-400 mg every 1-2 weeks 1
• Maintain colchicine for minimum 3 months even after symptom resolution 1

Corticosteroid Use - Critical Caveats

Corticosteroids are NOT recommended as first-line therapy (Class III recommendation) 1:

• Reserve corticosteroids only for: true NSAID allergy, recent peptic ulcer/GI bleeding, contraindication to anticoagulation when bleeding risk is high, or failure of NSAIDs plus colchicine 1
• If used, prescribe prednisone 0.2-0.5 mg/kg/day as low-to-moderate dose 1
• Critical pitfall: Corticosteroids favor recurrences and should be added to (not replace) NSAIDs and colchicine as triple therapy 1
• Taper very slowly over 3 months to avoid rebound pericarditis 1

Treatment of Underlying Rheumatic Activity

Since the pericardial rub indicates active rheumatic carditis, simultaneously address the underlying rheumatic fever 1:

• Confirm or rule out active streptococcal infection with throat culture and anti-streptolysin O titers
• Administer appropriate antibiotics if active infection present
• Initiate secondary prophylaxis for rheumatic fever prevention
• The pericarditis treatment does not replace rheumatic fever-specific management

Activity Restriction

Mandate exercise restriction until complete resolution 1:

• Non-athletes: Restrict exercise until symptom resolution and CRP normalization 1
• Athletes: Minimum 3-month restriction until symptom resolution AND normalization of CRP, ECG, and echocardiogram 1
• If myopericarditis present (elevated troponin): Absolute rest for minimum 6 months from disease onset, avoiding physical activity beyond normal sedentary activities 4

Monitoring and Follow-Up

• Evaluate response to therapy after 1 week - this is a critical checkpoint 1
• Repeat CRP and clinical assessment weekly initially 1
• Serial echocardiography if effusion present to monitor for progression or tamponade 1
• If troponin elevated, follow serial measurements and consider cardiac MRI to assess myocardial involvement 4

Management of Complications

Pericardial Effusion and Tamponade

If significant effusion develops or tamponade occurs 1:

• Pericardiocentesis with echocardiographic guidance is the procedure of choice (96% feasibility in loculated effusions) 1
• Major complication rate is only 1.3-1.6% with imaging guidance 1
• In RHD patients, pericardial fluid may show low glucose content even without infection - this is characteristic of rheumatoid/inflammatory etiology 5

Constrictive Pericarditis

While rare in acute pericarditis (<1% risk), RHD patients have intermediate risk (2-5%) for developing constriction 1:

• Monitor for signs of constriction during follow-up
• If constriction develops despite medical therapy, pericardiectomy is indicated (Class I, Level B) 1
• Ensure patient is steroid-free for several weeks before pericardiectomy 1

Common Pitfalls to Avoid

• Do not use corticosteroids as first-line therapy - they increase recurrence rates and should only be used for specific indications 1
• Do not taper NSAIDs too rapidly - this is a common cause of recurrence; follow the gradual tapering schedule 1
• Do not allow early return to exercise - premature activity can trigger recurrence or worsen myocardial involvement 1, 4
• Do not assume absence of effusion excludes significant pericarditis - only 60% of acute pericarditis cases have detectable effusion 1, 2
• Do not miss myocardial involvement - check troponin in all cases, as up to 50% may have myopericarditis requiring modified management 4, 3

Prognosis

• Pericarditis in RHD generally responds well to anti-inflammatory therapy within 1-2 weeks 6
• Myopericarditis (if present) has excellent prognosis with no evolution to heart failure or mortality when properly managed 4
• Recurrence risk is 15-30% without colchicine, reduced to approximately 7-15% with colchicine 1