What is the role of steroids, such as prednisone, in the treatment of constrictive pericarditis, particularly in patients with an inflammatory or autoimmune component?

Steroids in Constrictive Pericarditis

Steroids should NOT be routinely used in constrictive pericarditis, but may be considered selectively in patients with active inflammation (elevated ESR/CRP) and early/transient constriction, particularly when tuberculosis has been excluded. 1, 2

Evidence Against Routine Steroid Use

The most recent high-quality evidence demonstrates limited benefit for routine corticosteroid therapy:

• A large randomized trial with 1,400 participants found no significant difference in the combined endpoint of mortality, cardiac tamponade, or constrictive pericarditis between patients receiving adjunctive corticosteroids versus placebo in tuberculous pericarditis 1, 2
• The 2016 ATS/CDC/IDSA guidelines provide only a conditional recommendation against routine corticosteroid use in tuberculous pericarditis, citing very low certainty evidence 1, 2
• Systematic reviews have not demonstrated statistically significant mortality or constrictive pericarditis benefits from corticosteroids 1

When to Consider Steroids: The Transient Constriction Paradigm

Steroids may be beneficial in a subset of patients with "transient" or inflammatory constrictive pericarditis, identified by specific clinical and imaging markers:

High-Risk Patients Who May Benefit:

• Patients with large pericardial effusions and early signs of constriction 1, 2
• Those with high inflammatory markers (elevated ESR >40 mm/hr or CRP) in pericardial fluid or serum 1, 2, 3
• Patients with early signs of constriction on echocardiography (abnormal lateral/septal e' ratio or longitudinal strain ratio) 3
• HIV-positive patients with tuberculous pericarditis (though evidence is mixed) 1, 2

Evidence Supporting Selective Use:

• A 2021 study demonstrated that patients with higher baseline ESR who received anti-inflammatory therapy (including prednisone) showed improvement in constrictive physiology measured by lateral/septal e' velocity ratio and longitudinal strain 3
• Approximately 57% of patients treated with anti-inflammatory medications (including steroids) had clinical resolution of constriction during follow-up 3
• The 2004 ESC guidelines noted that tuberculostatic treatment combined with steroids may reduce mortality and need for pericardiectomy in tuberculous constrictive pericarditis, though this remains controversial 1

Specific Clinical Scenarios

Tuberculous Constrictive Pericarditis:

• If steroids are used, administer prednisone at 1-2 mg/kg/day (high doses needed because rifampicin induces hepatic metabolism) 1
• Maintain this dose for 5-7 days, then progressively taper over 6-8 weeks 1
• Alternative regimen: 60 mg/day for 4 weeks → 30 mg/day for 4 weeks → 15 mg/day for 2 weeks → 5 mg/day for week 11 1, 2
• Always combine with appropriate antituberculous therapy 1

Idiopathic/Autoimmune Constrictive Pericarditis:

• Initial conservative management with loop diuretics for volume management 4
• Trial of colchicine and NSAIDs first before considering steroids 4
• If steroids are necessary, use low-to-moderate doses (prednisone 0.2-0.5 mg/kg/day) 1
• Taper extremely slowly, particularly when crossing the critical threshold of 10-15 mg/day prednisone 1
• At doses <15 mg/day, decrease by only 1.0-2.5 mg at intervals of 2-6 weeks 1

Critical Pitfalls and Caveats

Major Risks of Steroid Use:

• Steroids favor chronicity and increase recurrence rates in acute and recurrent pericarditis 1, 5
• High-dose steroids are associated with higher recurrence rates compared to NSAIDs/colchicine 1
• Steroids should be avoided if bacterial or tuberculous infection cannot be excluded 1

When Steroids Are Contraindicated:

• Active or suspected bacterial pericarditis (including tuberculous) without concurrent antimicrobial therapy 1
• Patients who can tolerate NSAIDs and colchicine as first-line therapy 1, 5
• Chronic constrictive pericarditis without active inflammation (normal ESR/CRP) 3

Algorithmic Approach to Constrictive Pericarditis

Step 1: Assess for Active Inflammation

• Check ESR and CRP at baseline 3
• Perform echocardiography to assess lateral/septal e' velocity ratio and longitudinal strain patterns 3
• If ESR >40 mm/hr or CRP elevated with early constriction → consider trial of anti-inflammatory therapy 3

Step 2: Initial Conservative Management

• Start loop diuretics for symptomatic volume overload 4
• Initiate colchicine (0.5 mg once daily if <70 kg, twice daily if ≥70 kg) 4
• Add NSAIDs (ibuprofen 600 mg every 8 hours) if no contraindications 4
• Continue for at least 2-3 months while monitoring inflammatory markers 1

Step 3: Consider Steroids Only If:

• Specific indications exist: systemic inflammatory disease, post-pericardiotomy syndrome, pregnancy 1
• NSAID contraindications: true allergy, recent GI bleeding, high bleeding risk on anticoagulation 1
• Persistent symptoms despite adequate NSAIDs/colchicine for 2-3 months 1
• Active inflammation documented (elevated ESR/CRP) with early/transient constriction 3

Step 4: Monitor Response

• Serial echocardiography to assess improvement in lateral/septal e' ratio 3
• Track ESR and CRP normalization 3
• Clinical improvement in NYHA functional class 3
• If no improvement after 3-6 months of medical therapy, proceed to pericardiectomy evaluation 1, 4

Step 5: Definitive Treatment

• Pericardiectomy remains the definitive treatment for persistent symptomatic constrictive pericarditis 4
• Indicated for NYHA class II-III symptoms with persistent constriction on imaging 4
• Avoid in elderly patients, radiation-induced disease, very advanced symptoms, or myocardial fibrosis due to higher mortality 4

Special Populations

Tuberculous Pericarditis:

• The risk of developing constriction is 20-30% even with appropriate antituberculous therapy 1
• Steroids may reduce progression to constriction in HIV-negative patients but evidence remains controversial 1, 2
• Always combine steroids with appropriate antituberculous drug regimen for at least 6 months 1

Post-Cardiac Surgery:

• Constrictive pericarditis occurs in <1% of post-pericardiotomy syndrome cases 1
• Steroids are appropriate for post-pericardiotomy syndrome with documented inflammation 1
• Use low-dose prednisone (0.2-0.5 mg/kg/day) rather than high doses 1