Aetiological diagnosis in acute and recurrent pericarditis: when and how

Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis

The treatment of pericardial diseases is largely empirical because of the relative lack of randomized trials compared with other cardiovascular diseases. The main forms of pericardial diseases that can be encountered in the clinical setting include acute and recurrent pericarditis, pericardial effusion with or without cardiac tamponade, and constrictive pericarditis. Medical treatment should be targeted at the cause of the disease as much as possible. However, the cause of pericardial diseases may be varied and depends on the prevalence of specific diseases (especially tuberculosis). The search for an etiology is often inconclusive, and most cases are classified as idiopathic in developed countries where tuberculosis is relatively rare, whereas a tuberculous etiology is often presumed in developing countries where tuberculosis is endemic. The aim of the present article is to review current medical therapy for pericardial diseases, highlighting recent significant advances in clinical research, ongoing challenges and unmet needs. Following a probabilistic approach, the most common causes are considered (idiopathic, viral, tuberculous, purulent, connective tissue diseases and neoplastic pericardial disease). In this article, the therapy of idiopathic and more common forms of infectious pericarditis (viral and bacterial) is reviewed.

Management of pericardial diseases during pregnancy

Relatively few data have been published on the management of pericardial diseases during pregnancy. Pericardial involvement is sporadic during pregnancy, and pregnant women do not show any specific predisposition to pericardial diseases. The more common form of pericardial involvement is hydropericardium, usually as a benign mild effusion recorded in about 40% of pregnant women by the third trimester, followed by pericarditis as the more common disease requiring medical therapy. The general management of these conditions is not different from those of nonpregnant women, although specific precautions should be followed for specific diagnostic and therapeutic issues during pregnancy. If possible, pregnancy should be planned in a phase of disease quiescence. Nonselective cyclooxygenase inhibitors and aspirin can be used safely during the first and second trimester, but should be withdrawn later and in any case at gestational week 32, because of the possible effects on ductus arteriosus and renal function. Low-medium doses of prednisone are allowed during all pregnancy and breastfeeding. Colchicine is generally contraindicated during pregnancy, except in women with familial Mediterranean fever. These pregnancies should be followed by a dedicated multidisciplinary teams.

Innate versus acquired immune response in the pathogenesis of recurrent idiopathic pericarditis

The pathogenesis of recurrent pericarditis is still poorly understood and may be related either to viral infections or autoimmune and autoinflammatory disorders. The immune system plays a major role in the pathogenesis of the disease, modulating individual responses to different noxa and explaining the variable reported recurrence rate (ranging from 20% to 50% of patients) following an attack of acute or recurrent pericarditis. Increasing interest is currently being devoted to autoinflammatory disorders, a group of conditions characterized by spontaneously relapsing and remitting bouts of systemic inflammation without apparent involvement of antigen-specific T cells or significant production of auto-antibodies. Ongoing basic and clinical research is needed to provide further evidence for the understanding of this common and troublesome disease, and to develop targeted and more efficacious therapies.