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Mechanistic Deep Dive
IL-1 Pathway in Recurrent Pericarditis
- IL-1α and IL-1β key inflammatory drivers
- NLRP3 inflammasome activation
- Autoinflammatory mechanism in idiopathic recurrent pericarditis
- Rilonacept: IL-1α + IL-1β trap
- Anakinra: IL-1 receptor antagonist
- Effective for ~ 96% reduction in recurrence (RHAPSODY)
Constrictive Hemodynamics
- Fixed end-diastolic volume regardless of filling pressure
- Rapid early filling (initial filling unimpeded) then abrupt cessation
- âDip and plateauâ / âsquare root signâ
- Ventricular interdependence (filling of one ventricle compresses other)
- Respiratory variation due to fixed pericardial volume
Recent Trials & Updates
RHAPSODY (2020)
- N = 86 recurrent pericarditis
- Rilonacept SC weekly vs placebo
- 96% reduction in recurrence at 24 weeks
- FDA approved 2021
- Allows steroid tapering
AIRTRIP (2016)
- Anakinra in colchicine + steroid refractory pericarditis
- â recurrence
- Daily SC injection
COVID-19 Pericarditis
- SARS-CoV-2 myopericarditis
- mRNA vaccine-associated (young males, rare, mostly self-limited)
- Treatment: NSAID + colchicine; rest
High-Yield Specialist Points
Myopericarditis vs Perimyocarditis
- Both have pericardial + myocardial involvement
- Myocarditis-predominant: troponin highly elevated, LV dysfunction â CMR
- Pericarditis-predominant: troponin mild, normal LV
- Treatment: based on severity of myocardial involvement (Ch270)
- Exercise restriction critical
Purulent Pericarditis
- Rare but life-threatening
- Bacterial: Staph aureus, Strep pneumonia, anaerobes
- Risk: bacteremia, post-thoracic surgery, immunocompromised
- Treatment: IV antibiotics + surgical drainage + pericardiocentesis
- Mortality high
Tubercular Pericarditis
- Common globally
- Sub-acute / chronic
- Effusive â effusive-constrictive â constrictive
- High ADA in pericardial fluid (> 40)
- Treatment: 4-drug TB regimen + steroids (debated)
- Pericardiectomy if constrictive
Malignant Pericardial Effusion
- Common in lung, breast, lymphoma, melanoma
- Often hemorrhagic
- Cytology + flow cytometry
- Treatment: pericardiocentesis + pericardial window + treat malignancy
- Recurrent: sclerosing agents (bleomycin), tunneled catheter
Uremic Pericarditis
- BUN > 60 traditional cutoff (now less strict)
- Treatment: dialysis intensification
- Heparin during dialysis can worsen â heparin-free or citrate-based
Post-Cardiac Injury Syndromes
- Dressler syndrome (post-MI, 2-10 wk): autoimmune; treatment same as pericarditis
- Post-pericardiotomy syndrome (post-cardiac surgery): same physio
- Post-traumatic (penetrating, blunt)
Radiation Pericarditis
- Early (during/after radiation): acute pericarditis
- Late (10-30 years post): constrictive
- Common in old chest radiation (Hodgkinâs, breast, lung)
- Pericardiectomy if constrictive
Pericardiectomy Pearls
- Complete > partial
- Bilateral phrenic nerve preservation
- 5-15% perioperative mortality
- Symptoms improve over weeks-months
- May have post-op LV dysfunction (atrophy from chronic constriction)
Cardiac MRI in Pericardial Disease
- T2 hyperintensity = edema (active inflammation)
- Late gadolinium enhancement of pericardium
- Cine for ventricular interdependence
- Thickness assessment
- Differentiates myopericarditis
Pericardiocentesis Pearls
- Subxiphoid approach: angle 30° toward L shoulder
- Echo-guided preferred
- Confirm position with agitated saline
- Hemorrhagic fluid: aspirate slowly, send for clotting (compare to peripheral)
- Complications: arrhythmia, pneumothorax, hepatic puncture, ventricular puncture
Pearls
- Diagnosis: 2 of 4 (pain + rub + ECG + effusion)
- Treatment: NSAID + colchicine 3 mo; rilonacept for refractory recurrent (RHAPSODY)
- Tamponade: emergency pericardiocentesis; Beck triad, pulsus paradoxus, RA/RV collapse on echo
- Constrictive vs restrictive: tissue Doppler eâ preserved/â in constrictive
- TB pericarditis: common globally; effusive â constrictive; ADA helpful
- Pericardiectomy for chronic constrictive â definitive but high morbidity
- Avoid steroids first-line in acute pericarditis (â recurrence)