Clinical Presentation and Outcomes of Acute Pericarditis in a Large Urban Hospital in the United States of America

Background

Acute pericarditis is the most common presentation of pericardial diseases. Although generally benign, complications such as constrictive pericarditis, cardiac tamponade, and recurrence can occur.

Research Question

What are the clinical factors associated with adverse outcomes in acute pericarditis?

Study Design and Methods

We used an informatics-based search engine to search for International Classification of Diseases codes related to pericardial disease between January 1, 2009 and November 14, 2018 and then extracted clinical information, including only patients meeting the European Society of Cardiology criteria for acute pericarditis. We then evaluated the predictive value of clinical characteristics for adverse outcomes (cardiac tamponade, constrictive pericarditis, failure of therapy, recurrences, or death).

Results

We identified 240 patients with a first episode of pericarditis (51 [34-62] years, 56% males and 50% white). Pericarditis was determined to be idiopathic in 126 (53%) cases and related to cardiac injury in 79 (33%). During a median follow-up time of 179 (20-450) days, 82 (34%) patients experienced at least one adverse outcome. Subacute presentation was an independent predictor of adverse outcomes. Patients with postcardiac injury pericarditis had a lower incidence in the composite of failure of treatment and recurrence (13% vs 26%; P = .022) compared with patients with idiopathic pericarditis. Troponin I measurements were obtained in 167 patients (70%). Elevated troponin I levels were associated with lower incidence of recurrences (4% vs 17%; P = .024) and of the composite outcome (13% vs 36%; P = .004).

Interpretation

Acute pericarditis is associated with at least one adverse outcome in 34% of patients. Subacute presentation and idiopathic etiology are associated with higher incidence of adverse outcomes, whereas elevated troponin I levels identify a group with reduced risk of recurrences.

Pericardial diseases in patients with hypothyroidism

Hypothyroidism is a well-known cause of pericardial effusion (with an incidence of 3%-37%) and can cause cardiac tamponade in severe cases. In this review, we present the current knowledge on the epidemiology of hypothyroid-induced pericardial diseases, the mechanism through which low thyroid hormone levels affect the pericardium, the associated clinical manifestations, diagnostic tests and management options. Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space. Interestingly, autoimmunity does not seem to play a major role in the pathophysiology, and a majority of effusions are asymptomatic due to slow fluid accumulation. The diagnosis is generally made when the pericardial disease is associated with an elevated thyroid-stimulating hormone level, and other secondary causes are excluded. Management consists of thyroid replacement therapy, along with pericardial drainage in case of tamponade.In conclusion, hypothyroidism-induced pericardial diseases are underdiagnosed. Initiating treatment early in the disease process and preventing complications relies on early diagnosis through systematic screening per guidelines.

Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge

We report a case of acute viral pericarditis and cardiac tamponade in a patient with COVID-19 to highlight the associated treatment challenges, especially given the uncertainty associated with the safety of standard treatment. We also discuss complications associated with delayed diagnosis in patients who potentially may need mechanical ventilation.

Clinical Utility of Cardiac Magnetic Resonance Imaging in Pericardial Diseases

Background:

Pericardial diseases are relatively common in clinical practice and encountered in various clinical settings with consequent significant morbidity and mortality. However, the diagnosis as well as management can be complex and challenging, as the clinical presentation is usually non-specific. Therefore, there is an increasing role for Cardiac Magnetic Resonance Imaging (CMR) as an imaging tool to facilitate the diagnosis of pericardial diseases.

Conclusion:

Herein we describe conventional and unique CMR approaches to provide an increased non-invasive understanding of the pericardium in health and disease including a novel method to diagnose constrictive pericarditis via radio-frequency tissue tagging by defining unique visceral-parietal adherence patterns easily learned by the cardiologist and radiologist.

Age- and sex-based differences in patients with acute pericarditis

BACKGROUND

Acute pericarditis has a wide spectrum of clinical presentations largely depending on underlying aetiologies. We assessed the role of age and sex in the clinical features and outcome of acute pericarditis.

MATERIALS AND METHODS

A total of 240 consecutive patients hospitalized with a first episode of acute pericarditis were included. At baseline demographics, clinical features, laboratory and imaging findings and medical therapy were recorded. Patients were followed up for at least 18 months for complications. Data comparisons were performed according to sex and age (≤60 or >60 years).

RESULTS

The male/female ratio was 1.42, and 56% of patients were >60 years. Younger patients depicted more often chest pain (P = .001), fever and rubs (P < .001 for both), ST elevation and PR depression (P = .032 and .009, respectively), higher CRP values (P = .009) and less often dyspnoea (P = .046) and pericardial effusion (P = .036). Moreover, they received less often glucocorticoids (P < .001) and depicted less atrial fibrillation (P = .003) and a higher rate of recurrent pericarditis (P = .013). After multivariate adjustment for confounders, age >60 years remained an independent predictor for a lower risk of recurrent pericarditis (hazard ratio 0.60, 95% CI: 0.39-0.96, P = .033). Regarding sex, females were older (P = .007), showed less often ST elevation and PR depression (P < .001 and .002, respectively) and had a higher baseline heart rate (P = .02). Sex was not associated with recurrent pericarditis risk.

CONCLUSIONS

Patients with acute pericarditis have distinct presenting clinical, biochemical and prognostic features according to age and sex. Awareness of such differences is important for clinical decision-making.

A Deep Learning Algorithm for Detecting Acute Pericarditis by Electrocardiogram

(1) Background: Acute pericarditis is often confused with ST-segment elevation myocardial infarction (STEMI) among patients presenting with acute chest pain in the emergency department (ED). Since a deep learning model (DLM) has been validated to accurately identify STEMI cases via 12-lead electrocardiogram (ECG), this study aimed to develop another DLM for the detection of acute pericarditis in the ED. (2) Methods: This study included 128 ECGs from patients with acute pericarditis and 66,633 ECGs from patients visiting the ED between 1 January 2010 and 31 December 2020. The ECGs were randomly allocated based on patients to the training, tuning, and validation sets, at a 3:1:1 ratio. We used raw ECG signals to train a pericarditis-DLM and used traditional ECG features to train a machine learning model. A human–machine competition was conducted using a subset of the validation set, and the performance of the Philips automatic algorithm was also compared. STEMI cases in the validation set were extracted to analyze the DLM ability of differential diagnosis between acute pericarditis and STEMI using ECG. We also followed the hospitalization events in non-pericarditis cases to explore the meaning of false-positive predictions. (3) Results: The pericarditis-DLM exceeded the performance of all participating human experts and algorithms based on traditional ECG features in the human–machine competition. In the validation set, the pericarditis-DLM could detect acute pericarditis with an area under the receiver operating characteristic curve (AUC) of 0.954, a sensitivity of 78.9%, and a specificity of 97.7%. However, our pericarditis-DLM also misinterpreted 10.2% of STEMI ECGs as pericarditis cases. Therefore, we generated an integrating strategy combining pericarditis-DLM and a previously developed STEMI-DLM, which provided a sensitivity of 73.7% and specificity of 99.4%, to identify acute pericarditis in patients with chest pains. Compared to the true-negative cases, patients with false-positive results using this strategy were associated with higher risk of hospitalization within 3 days due to cardiac disorders (hazard ratio (HR): 8.09; 95% confidence interval (CI): 3.99 to 16.39). (4) Conclusions: The AI-enhanced algorithm may be a powerful tool to assist clinicians in the early detection of acute pericarditis and differentiate it from STEMI using 12-lead ECGs.

A risk score for pericarditis recurrence

BACKGROUND

Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis.

MATERIALS AND METHODS

We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51 months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation.

RESULTS

We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups.

CONCLUSIONS

A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.

Recurrent pericarditis: a case report and literature review

BACKGROUND

Recurrence affects about 30% (20% to 50%) of patients within 18 months after the initial episode of acute pericarditis resulting in subsequent rehospitalizations. Bearing in mind high treatment costs of patients admitted to hospital with acute and recurrent pericarditis, there is a need to optimize the treatment of both of these conditions.

MATERIALS AND METHODS

We present a case of recurrent pericarditis. The first episode of pericarditis was diagnosed in 2006. Three months later the patient was hospitalized due to clinical symptoms suggesting recurrence of a past condition. Ten years after the initial episode of acute pericarditis the patient was hospitalized for the treatment of recurrent pericarditis. The search for etiology of the disease was unsuccessful, the patient received treatment with nonsteroidal anti-inflammatory drugs; empiric antimicrobial therapy was also administered.

RESULTS AND CONCLUSIONS

Acute pericarditis is the most common disease of the pericardium encountered in clinical practice. Colchicine has been demonstrated as a first-line drug to be added to conventional anti-inflammatory therapies in patients with a first episode of pericarditis or its recurrences in order to improve the response to therapy and reduce recurrences. Despite a large amount of new data, there are still several issues that require additional research and clarification, including the search for new individualized therapies, the best duration of treatment for patients with pericardial diseases, and optimization of patient follow-up in order to collect data on long-term outcomes that would allow shortening the duration of in-patient treatment and reduction of recurrences.

Clinical Burden and Unmet Need in Recurrent Pericarditis: A Systematic Literature Review

Inflammation of the pericardium (pericarditis) is characterized by excruciating chest pain. This systematic literature review summarizes clinical, humanistic, and economic burdens in acute, especially recurrent, pericarditis, with a secondary aim of understanding United States treatment patterns and outcomes. Short-term clinical burden is well characterized, but long-term data are limited. Some studies report healthcare resource utilization and economic impact; none measure health-related quality-of-life. Pericarditis is associated with infrequent but potentially life-threatening complications, including cardiac tamponade (weighted average: 12.7% across 10 studies), constrictive pericarditis (1.84%; 9 studies), and pericardial effusion (54.7%; 16 studies). There are no approved pericarditis treatments; treatment guidelines, when available, are inconsistent on treatment course or duration. Most recommend first-line use of conventional treatments, for example, nonsteroidal antiinflammatory drugs with or without colchicine; however, 15-30% of patients experience recurrence. Second-line therapy may involve conventional therapies plus long-term utilization of corticosteroids, despite safety issues and the difficulty of tapering or discontinuation. Other exploratory therapies (eg, azathioprine, immunoglobulin, methotrexate, anakinra) present steroid-sparing options, but none are supported by robust clinical evidence, and some present tolerability challenges that may impact adherence. Pericardiectomy is occasionally pursued in treatment-refractory patients, although data are limited. This lack of an evidence-based treatment pathway for patients with recurrent disease is reflected in readmission rates, for example, 12.2% at 30 days in 1 US study. Patients with continued recurrence and inadequate treatment response need approved, safe, accessible treatments to resolve pericarditis symptoms and reduce recurrence risk without excessive treatment burden.

Usefulness of neutrophil-to-lymphocyte ratio for predicting acute pericarditis outcomes

BACKGROUND

In daily practice, C-reactive protein (CRP) may be used to predict recurrence and treatment response in patients with acute pericarditis; however, the predictive role of CRP might be insufficient for clinical prediction in some patients. In this study, we aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and the composite endpoint of pericarditis recurrence and/or tamponade within 1 year in patients with acute pericarditis.

METHODS

A total of 104 patients diagnosed with acute idiopathic pericarditis (mean age 42.8 ± 15.2 years, 55.8% male) were included in the study. Physical examination findings of these patients, electrocardiography, echocardiography, chest X-ray and laboratory findings were evaluated and analysed. During the 1-year follow-up, the composite of cardiac tamponade and/or pericarditis recurrence was investigated as the primary endpoint of the study.

RESULTS

Compared to the group without the composite outcome, the group with the composite outcome had significantly higher rates of moderate and severe pericardial effusion (p < 0.01) and higher white blood cell (WBC) count (p:0.001), platelet count (p = 0.003), NLR (2.14 (1.49-3.02) vs 6.60 (5.50-8.68); p < 0.001) and high-sensitivity C-reactive protein (hs-CRP) (8.01 (5.1-24.5 vs 69.5 (40.8-128); p:0.001). Higher hs-CRP (p < 0.001), WBC (p:0.001), NLR (p < 0.001) and platelets (p:0.02) were associated with pericarditis recurrence. NLR and hs-CRP were independently associated with the composite endpoint (p < 0.001 and p < 0.001, respectively).

CONCLUSION

NLR and hs-CRP were found to be independent predictors for the composite endpoint of tamponade and/or recurrence in acute pericarditis patients during the 1-year follow-up. Similar to hs-CRP, NLR may also be used for risk assessment in patients with idiopathic pericarditis.

Spontaneous pneumomediastinum mimicking acute pericarditis

ST elevations on electrocardiogram (ECG) have a broad differential diagnosis that can vary from benign to more ominous pathologies. These include early repolarization, coronary vasospasm, acute pericarditis, ST-elevation myocardial infarction, ventricular aneurysms, and dissecting aneurysm of the aorta reaching the pericardium. ST-segment changes may also provide a clue to the presence of spontaneous pneumomediastinum (SPM). These ECG changes are seldom reported in literature. We describe two SPM cases with concomitant pneumopericardium that closely mimicked acute pericarditis with a deceptive clinical spectrum.

Acute Pericarditis as a Presentation of Adrenal Insufficiency

Acute pericarditis as a presenting sign of adrenal insufficiency is rarely reported. We present a rare case that highlights pericarditis as a clinical presentation of secondary adrenal insufficiency later complicated by cardiac tamponade. A 44-year-old lady who presented to the hospital with a one-day history of pleuritic chest pain and shortness of breath. In the emergency room, she had a blood pressure of 70/35 mmHg. Laboratory evaluation revealed white blood cell count of 16.08 k/cumm with neutrophilia, normal renal function and elevated troponin (0.321 ng/mL, normal 0.000-0.028). An electrocardiogram (EKG) showed sinus tachycardia, low voltage, PR suppression and ST changes consistent with acute pericarditis. Echocardiogram showed small pericardial effusion without tamponade physiology. Infectious workup was negative; she was thought to have acute adrenal insufficiency likely secondary to viral pericarditis. We treated the patient with high dose nonsteroidal anti-inflammatory drugs (NSAIDS) and hydrocortisone. Three weeks later, she presented to emergency room with complaints of persistent nausea, vomiting, chills, weakness. Her blood pressure was 49/23 mmHg. Random serum cortisol level was <1.2 mcg/dl (normal A.M. specimens 3.7-19.4 mcg/dl). Echocardiogram showed loculated pericardial fluid adjacent to the right ventricle with echocardiographic evidence of tamponade. Emergent pericardiocentesis yielded 250 ml of straw color fluid. Blood pressure improved after the procedure. The patient was initially started on IV stress dose steroids, but following clinical stabilization, hydrocortisone was switched to a physiological dose of 15 mg in am and 10 mg in pm. Although the mechanism of pericarditis in adrenal failure is unknown, this clinical presentation may help early diagnosis of adrenal failure and pericarditis. Early recognition and prompt treatment of this rare presentation are critical to prevent morbidity and mortality.

Case Report: ST-Segment Elevation in a Man With Acute Pericarditis

Background: Acute pericarditis is a rapid inflammatory condition of the pericardium with both infectious and non-infectious etiology. Most acute pericarditis is self-limited, with a small portion evolving rapidly. The definitive diagnosis of acute pericarditis often requires detailed physical examination, ECG, echocardiography, blood analysis and chest X-ray. It's usually challenging to distinguish acute pericarditis from ST-elevated myocardial infarction (STEMI) due to the similar ECG characteristics (ST segment change). Here we present a case of purulent pericarditis probably caused by esophageal perforation.

Case: A 52 year-old male presented with chest pain and dyspnea for 16 h. ST-segment elevation and positive cardiac markers lead to the initial diagnosis of ST-elevated myocardial infarction. Coronary angiography demonstrated normal coronary artery, while transthoracic echocardiography (TTE) showed massive pericardial effusion. Then, pericardiocentesis was performed with 250 ml of yellowish-green pus-like fluid extracted. A detailed history examination revealed a week history of possible esophageal perforation caused by a fishbone. And a further computed tomography (CT) demonstrated the presence of pneumomediastinum, and effusions in mediastinum, which lead to the diagnosis of purulent pericarditis. However, the patient's family refused further treatment and the patient died soon after discharge.

Conclusion: The differential diagnosis of chest pain should include acute pericarditis, which can be equally critical and fatal. And it's important to note the peculiar characteristics of acute pericarditis, which include concave and diffused ST-segment elevation, PR segment depression, and the ratio of ST-segment elevation to T wave >0.24 in lead V6. Moreover, comprehensive medical history and physical examination are crucial to the differential diagnosis of chest pain patients.

Impact of Colchicine Monotherapy on the Risk of Acute Pericarditis Following Atrial Fibrillation Ablation

BACKGROUND

Acute pericarditis is a known complication of ablation procedures for atrial fibrillation (AF).

OBJECTIVES

This study aimed to evaluate the benefits of colchicine monotherapy in terms of reducing the risk of pericarditis and related hospitalization rate in AF patients undergoing catheter ablation.

METHODS

Consecutive AF patients undergoing first catheter ablation were classified into 3 groups based on their colchicine use: Group 1: no colchicine; group 2: colchicine from 7 days before to 1 month after ablation; and group 3: colchicine from the day of the procedure to 1 month after. Standard institutional protocol was used to follow all patients for 1 year.

RESULTS

A total of 1,075 patients were classified into groups 1 (n = 607), 2 (n = 213), and 3 (n = 255). Symptoms of acute pericarditis were reported in 129 patients (12%): group 1: n = 106 (17.5%); group 2: n = 4 (1.9%); and group 3: n = 19 (7.5%); P < 0.001. Rate of mild-moderate as well as severe pericarditis were significantly lower in group 2. In the multivariable regression analysis, pre- and post-ablation colchicine use was seen to be associated with significantly lower risk of acute pericarditis and related hospitalization compared with the other 2 groups. In addition, at 1-year follow-up, arrhythmia-free survival rate was significantly higher in paroxysmal AF patients receiving colchicine compared with the no-colchicine population.

CONCLUSIONS

Colchicine therapy starting 7 days before to 1 month after the ablation procedure was associated with significantly lower risk of acute pericarditis and related hospitalization. In addition, paroxysmal AF patients receiving colchicine had a higher arrhythmia-free survival rate compared with those not receiving colchicine.

Cardiac MRI in Immune Checkpoint Inhibitor Associated Pericarditis

Checkpoint inhibitors are novel and promising anticancer agents. However, acute pericarditis is the second most common chemotherapy-associated cardiotoxicity and associated with high mortality up to 21%. Cardiac MRI offers a one-stop-shop cardiac analysis to precisely detect chemotherapy-associated cardiotoxicity without nephrotoxic contrast dye and ionizing radiation.

Infliximab-Induced Lupus in a Patient With Psoriatic Arthritis Who Presented With Cardiac Tamponade: A Case Report

Psoriatic arthritis (PsA) is a chronic, immune-mediated inflammatory condition, and the proinflammatory cytokine tumor necrosis factor-α (TNF-α) plays a major pathogenic role in the development and progression of PsA. Anti-TNF-α therapies, such as the monoclonal antibody infliximab, are used to treat patients whose PsA has not responded favorably to conventional anti-rheumatic drugs. However, exposure to anti-TNF-α therapeutics can lead to drug-induced lupus erythematosus (DILE), which may rarely be accompanied by cardiac manifestations. Here, we describe a rare case of drug-induced lupus erythematosus secondary to infliximab therapy for PsA and psoriasis in a patient who presented with life-threatening acute pericarditis and cardiac tamponade. Newly developed skin rashes, newly elevated autoimmune indicators, and punch biopsy results indicating subacute cutaneous lupus collectively supported a DILE diagnosis within the context of infliximab use. Pericardiocentesis, colchicine, and corticosteroids alleviated symptoms, and infliximab was replaced with alternate therapy. This case highlights the importance of early recognition of the possible serious and uncommon adverse reactions from infliximab therapy. Prompt initiation of appropriate treatment and discontinuation of the offending agent are critical in cases of drug-induced lupus erythematosus, particularly when rare cardiac complications occur.

Incessant Pericarditis With Recurrent Cardiac Tamponade as the Manifestation of Autoimmune Polyglandular Syndrome Type II

A 23-year-old man was admitted for acute pericarditis that evolved to cardiac tamponade and shock with need of emergent pericardiocentesis and inotropic support. Corticosteroid therapy was successful, but despite a gradual tapering, the patient relapsed. Incidentally, the patient developed hyperkalemia with hyponatremia. Subsequent hormonal measurements confirmed autoimmune polyglandular syndrome type-2. (Level of Difficulty: Intermediate.).

Temporal Trend, Prevalence, Predictors, and Outcomes of Pericardial Diseases in Patients Undergoing Transcatheter Aortic Valve Repair

Background Pericardial disease (PD) - acute pericarditis (AP) and pericardial effusion (PE) - is a rare complication of transcatheter aortic valve repair (TAVR) although its prevalence, predictors, and outcomes are not well studied. Methods We used the National Inpatient Sample (NIS) database to find patients who received TAVR between 2011 and 2018. TAVR patients were divided into two groups: with and without PD (AP and/or PE). The baseline characteristics between the two groups were compared using the Chi-square test and student t-test. Variables with a p-value of 0.20 or less from the univariate logistic regression were included in the multivariate logistic regression to find independent predictors of PD in TAVR patients. Results Out of 218,340 TAVR hospitalizations, 4323 (1.2%) had a concurrent diagnosis of PD. TAVR patients with PD were older (81 ± 7 vs 80 ± 6 years, p < 0.05), more likely to be females (62 vs 46%, p < 0.001), white (84.2 vs 82.9%, p = 0.83), and had a higher burden of comorbidities (Table 3). TAVR patients with PD had higher in-hospital mortality rate (12.3 vs 1.9%, p < 0.001), mean length of stay (8.4 vs 5.3 days, p < 0.001), and mean total hospital cost ($283,389 vs $224,544, p < 0.001). Age > 75, female sex, atrial fibrillation (Afib), atrial flutter (Aflutter), peripheral vascular disease (PVD), coagulopathy, cirrhosis, malnutrition, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and pacemaker (PM) implantation were the independent predictors of PD in TAVR patients. Conclusion Older, white females with a higher burden of comorbidities and cardiovascular procedures are at higher risk of pericardial complications of TAVR procedure. Sex-based disparities in the prevalence of PD after TAVR is an area of further research. Careful selection of patients for TAVR is essential to reduce the burden of these complications.

Spodick's Sign: A Case Report and Review of Literature

Acute pericarditis is commonly diagnosed in patients who present with chest pain. Accurate diagnosis of acute pericarditis is essential because of its relative similarity to ST-elevation myocardial infarction (STEMI) in both clinical presentation and electrocardiogram (EKG) changes. Additionally, troponin elevation is occasionally seen in acute pericarditis due to myocardial involvement (myopericarditis), which makes accurate diagnosis more challenging. A 12-lead EKG remains the most useful diagnostic test in differentiating acute pericarditis from STEMI. Spodick's sign is a less recognized electrocardiographic feature of acute pericarditis and is frequently overlooked by clinicians. We present a case of a 52-year-old male who initially presented with acute onset substernal chest pain. His EKG revealed diffuse subtle ST elevation and downsloping TP segment (Spodick's sign). A coronary angiogram demonstrated normal coronaries which eliminated the possibility of coronary artery disease. In this article, we will discuss how to differentiate between acute pericarditis and myocardial infarction, with a focus on Spodick's sign, amongst other EKG findings suggestive of pericarditis.

Novel Pathophysiological, Diagnostic and Therapeutic Concepts in Acute and Recurrent Pericarditis

Acute pericarditis is the most frequent pericardial disease characterized by inflammation of the pericardial layers resulting in pain, dyspnea and fatigue. Often limited to an isolated event, up to 30% of patients experience one or more recurrences. There is limited knowledge about the pathophysiology of this disease, possibly due to the limited availability of animal models. More recently, following seminal clinical trials with colchicine and interleukin-1 (IL-1) blockers and a novel murine model of acute pericarditis using zymosan A, it has become clear that the NLRP3 (NACHT, leucine-rich repeat, and pyrin domain-containing protein 3) inflammasome/IL-1 β axis plays a central role in driving acute pericardial inflammation and in sustaining this process during recurrences. Diagnostic management of pericarditis has been implemented with multimodality imaging including echocardiography, cardiac computed tomography, and cardiac magnetic resonance. These imaging modalities provide essential diagnostic and pathogenetic information, and are able to characterize pericardial inflammation, allowing to refine risk stratification and personalize treatment. Recent acquisitions yield relevant implications with regard to the therapeutic management of acute and recurrent pericarditis. Non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are cornerstone therapies either for acute and recurrent pericarditis. However, the benefits of targeted agents, such as anakinra - a recombinant human IL-1 receptor antagonist - and rilonacept - an IL-1 α /IL-1 β trap, are being increasingly recognized. To this end, phenotyping patients with pericarditis and addressing such therapies to those presenting with auto-inflammatory features (elevated C-reactive protein, sustained pericardial and systemic inflammation, multiple recurrences) is of utmost importance to identify patients who might be more likely to benefit from NLRP3 inflammasome/IL-1 β pathway blockade.

An Atypical Etiology of Acute Pericarditis: A Case Report

Acute pericarditis is caused by inflammation of the pericardial sac and is characterized by sharp and pleuritic chest pain, which is accompanied by a pericardial friction rub and serial electrocardiogram (ECG) changes. Although there are many known etiologies of pericarditis, we present the first known case of a herbal supplement, the Tejocote root, causing acute pericarditis in a previously healthy 23-year-old female. Her ECG showed t-wave inversions that resolved with colchicine and non-steroidal anti-inflammatory drug therapy. Prior studies have demonstrated that it can cause adverse cardiovascular effects, but this is the first documented case of the Tejocote root causing acute pericarditis. This case report reinforces the importance of inquiring about supplements patients may be taking, especially when looking for the etiology of pericarditis.

Atypical Electrocardiogram in Acute Pericarditis: A Case Report

Pericarditis is a disorder defined by inflammation of the pericardium, commonly presenting with chest pain, fever, and pericardial friction. Electrocardiography (EKG) is frequently utilized to diagnose pericarditis, as it frequently reveals particular changes like ST-segment elevations and PR-segment depressions. Nevertheless, there are cases where individuals show all symptoms of pericarditis yet present an atypical or irregular EKG. This case report intends to highlight the case of a patient who came to an outpatient medical facility with all the common symptoms of pericarditis yet presented an atypical electrocardiogram. Moreover, this report intends to look into the hypothesis that in patients showing symptoms of pericarditis but with an atypical EKG, we might be looking at an irregular or even non-specific variant of pericarditis. This highlights the value of an extensive diagnostic approach consisting of high-quality imaging studies, such as transthoracic echocardiography, as well as medical assessments if an EKG does not give definite proof of pericarditis.

Acute pericarditis: A peculiar manifestation of common variable immune deficiency

Common variable immune deficiency (CVID) is known as the most prevalent symptomatic inborn error of immunity associated with autoimmune and inflammatory complications in addition to recurrent infections. In this study, we investigated the prevalence of acute pericarditis as a complication in the past medical history of 337 CVID patients. We found five patients (1.5%) that had experienced acute pericarditis, and described the medical history of three patients.