**2.2 Recurrent pericarditis**

Recurrent pericarditis is the most common complication of acute pericarditis, and it happens in 30% of patients with a first attack of acute pericarditis. Recurrent pericarditis is defined with a symptom-free interval of 4–6 weeks or longer after the first episode of acute pericarditis.

Diagnosis is established by C-reactive protein, computed tomography, and/or cardiac magnetic resonance imaging showing pericardial inflammation.

Commonly prescribed anti-inflammatory therapies for recurrent pericarditis are aspirin, ibuprofen, indomethacin, and colchicine (**Table 2**). Colchicine is recommended for at least 6 months. In cases of incomplete response to aspirin/NSAIDs and colchicine, corticosteroids may be used. However, severe side effects of corticosteroids were reported in about 25% of patients with high oral dose of corticosteroids. In order to avoid systemic side effects of corticosteroids, the intrapericardial route has been proposed [4, 5]; however, this technique requires further investigation. Drugs such as immunoglobulin, anakinra, or azathioprine are considered as third-line therapy in cases of non-response to aspirin/NSAIDS, colchicine, or


#### **Table 1.**

*Commonly prescribed anti-inflammatory therapy for acute pericarditis.*


**5**

**Figure 1.**

*Prologue: Introduction to Advanced Concepts in Pericardial Disease*

**3. Pericardial effusion and cardiac tamponade**

corticosteroids. As a last resort, pericardiectomy is considered after a thorough trail

Pericarditis which has concomitant myocardial involvement is referred to as myopericarditis. The classical presentation of myopericarditis is chest pain with other signs of pericarditis, in addition to the elevation of markers of myocardial damage. Viral infections are the most common cause in developed countries, whereas infectious causes such as tuberculosis are common in developing countries. In cases of suspected myopericarditis, coronary angiography is recommended in order to rule out acute coronary syndrome. Cardiac magnetic resonance is also recommended for the confirmation of myocardial involvement. Hospitalization, rest, and avoidance of physical activity beyond normal sedentary activities are recommended in nonathletes and athletes with myopericarditis for a period of 6 months.

Pericardial effusion is classified according to onset as acute, subacute, and chronic when lasting >3 months. The pericardial effusion, which was caused by inflammation leading to increased production of pericardial fluid, is called exudate pericardial effusion. On the other hand, the accumulation of pericardial fluid caused by decrease reabsorption due to an increase in systemic venous pressure as a result of congestive heart failure or pulmonary hypertension is called transudate pericardial effusion. As of diagnosis, transthoracic echocardiography is recommended (**Figure 1**), and it can assess the size of the pericardial effusion (mild, < 10 mm; moderate, 10–20 mm; or large, > 20 mm), distribution (circumferential or loculated), and

Pericardial effusion is often associated with known or unknown medical conditions such as infections (viral, bacterial, and tuberculosis), cancer, connective

*The echocardiographic imaging for pericardial effusion. LA, left atrium; LV, left ventricle.*

C-reactive protein dosage should be considered to guide the treatment duration and assess the response to therapy. After the normalization of C-reactive protein, a gradual tapering of therapies should be considered, tailored to symptoms, stopping

*DOI: http://dx.doi.org/10.5772/intechopen.86164*

of unsuccessful medical therapy.

a single class of drugs at a time.

**2.3 Myopericarditis**

hemodynamic effects.

#### **Table 2.**

*Commonly prescribed anti-inflammatory therapy for recurrent pericarditis.*

#### *Prologue: Introduction to Advanced Concepts in Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.86164*

corticosteroids. As a last resort, pericardiectomy is considered after a thorough trail of unsuccessful medical therapy.

C-reactive protein dosage should be considered to guide the treatment duration and assess the response to therapy. After the normalization of C-reactive protein, a gradual tapering of therapies should be considered, tailored to symptoms, stopping a single class of drugs at a time.

### **2.3 Myopericarditis**

*Inflammatory Heart Diseases*

as an autoimmune disease.

**2.2 Recurrent pericarditis**

first episode of acute pericarditis.

**Drug Usual dosing Therapy** 

*Commonly prescribed anti-inflammatory therapy for acute pericarditis.*

**Drug Usual dosing Therapy** 

Aspirin 750–1000 mg every 8 hours

Colchicine 0.5 mg per day (<70 kg)

0.5 mg twice a day (≥70 kg)

6–8 hours

(<70 kg) 0.5 mg twice a day (≥70 kg)

*Commonly prescribed anti-inflammatory therapy for recurrent pericarditis.*

Aspirin 500–1000 mg every

Colchicine 0.5 mg per day

adjunct to aspirin/NSAID therapy (**Table 1**). Evaluation of response to antiinflammatory therapy is recommended after 1 week. Low-dose corticosteroids can be considered in cases of contraindication/failure of aspirin/NSAIDs and colchicine, when an infectious cause is excluded or when there is a specific indication such

Recurrent pericarditis is the most common complication of acute pericarditis, and it happens in 30% of patients with a first attack of acute pericarditis. Recurrent pericarditis is defined with a symptom-free interval of 4–6 weeks or longer after the

Diagnosis is established by C-reactive protein, computed tomography, and/or

**duration**

Ibuprofen 600 mg every 8 hours 1–2 weeks Decrease doses by 250–500 mg every

Commonly prescribed anti-inflammatory therapies for recurrent pericarditis are aspirin, ibuprofen, indomethacin, and colchicine (**Table 2**). Colchicine is recommended for at least 6 months. In cases of incomplete response to aspirin/NSAIDs and colchicine, corticosteroids may be used. However, severe side effects of corticosteroids were reported in about 25% of patients with high oral dose of corticosteroids. In order to avoid systemic side effects of corticosteroids, the intrapericardial route has been proposed [4, 5]; however, this technique requires further investigation. Drugs such as immunoglobulin, anakinra, or azathioprine are considered as third-line therapy in cases of non-response to aspirin/NSAIDS, colchicine, or

**duration**

Ibuprofen 600 mg every 8 hours Weeks–months Decrease doses by 200–400 mg every

At least 6 months

Indomethacin 25–50 mg every 8 hours Weeks–months Decrease doses by 25 mg every

**Tapering**

**Tapering**

1–2 weeks

3 months Not mandatory

1–2 weeks Decrease doses by 250–500 mg every 1–2 weeks

1–2 weeks

1–2 weeks

Not mandatory

Weeks–months Decrease doses by 250–500 mg every 1–2 weeks

cardiac magnetic resonance imaging showing pericardial inflammation.

**4**

**Table 2.**

**Table 1.**

Pericarditis which has concomitant myocardial involvement is referred to as myopericarditis. The classical presentation of myopericarditis is chest pain with other signs of pericarditis, in addition to the elevation of markers of myocardial damage. Viral infections are the most common cause in developed countries, whereas infectious causes such as tuberculosis are common in developing countries.

In cases of suspected myopericarditis, coronary angiography is recommended in order to rule out acute coronary syndrome. Cardiac magnetic resonance is also recommended for the confirmation of myocardial involvement. Hospitalization, rest, and avoidance of physical activity beyond normal sedentary activities are recommended in nonathletes and athletes with myopericarditis for a period of 6 months.
