Pericardial Disease and How Your Doctor Cares for You

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart Vascular, and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Allan Klein, MD:

My name is Dr. Allen Klein. I'm the Director of the Center for the Diagnosis and Treatment of Pericardial Diseases at the Cleveland Clinic. And it's my great pleasure talking about pericarditis.

Allan Klein, MD:

I think this field is very exciting. At this moment, there's a explosion of publications on pericarditis. In particular, you have advanced imaging that helps diagnose pericarditis and now you have therapeutics such as the IL-1 blockers, rilonacept in the treatment. Patients are coming here for these new imaging and treatments.

Allan Klein, MD:

So let me start at the beginning. What pericarditis? Pericarditis is the inflammation of the sac around the heart. We've come a long way from an old diagnosis from for many years used EKG and clinical criteria to, as I mentioned, advanced imaging and what we call complicated pericarditis. There's many clinical syndromes for pericarditis, including acute and recurrent pericarditis, pericardial fusion, constrictive pericarditis, effusive constriction, masses in the pericardium and diverticulum of the pericardium and cysts as well.

Allan Klein, MD:

With regard to most of the patients coming to see us at our pericardial center, the most common would be probably acute and recurrent pericarditis. Let's go over what this means. So acute pericarditis means is that you get, let's say a viral illness and the sac becomes very, very inflamed. Most of the time, this acute episode goes away and you never see the doctor, but sometimes it becomes recurrent. That means that the acute episode gets better for around four to six weeks and then it comes back so that you call that recurrent pericarditis.

Allan Klein, MD:

Another term that people use is incessant pericarditis. That means that for the first three months, the acute episode doesn't get better. So it's nonstop incessant, which may be a little more aggressive. And after three months it becomes chronic. So acute recurrent pericarditis would be the most common.

Allan Klein, MD:

Then other things that we would see would probably be constrictive pericarditis when the sac gets hardened and thickened and patients get shorter breath, get so-called heart failure. Often this is treated surgically and occasionally with medical therapy.

Allan Klein, MD:

What do we have here at Cleveland Clinic? We have a Pericardial Center of excellence where the concept that's multidisciplinary, where patients could come for one to two days and see the cardiologists, and then see different subspecialties, such as rheumatology, get advanced imaging, including MRI and echo, collect any bloods that are necessary for assessing pericarditis, sometimes see the surgeon, have a heart catheterization to measure pressure. So within one to two days, the patients will get their diagnosis and the proper management going. So this is quite unique.

Allan Klein, MD:

What are some of the symptoms for pericarditis? These include, as I mentioned, chest pain. Chest pain, when you take a deep breath, it hurts and you have to sit forward and when you lie back, it hurts even more, often goes to the left shoulder. Another come thing would be signs of heart failure, shortness of breath, ankle swelling, belly swelling.

Allan Klein, MD:

In the U.S., the most common cause would be idiopathic or viral pericarditis. So you get a flu-like illness, you get a cold and you get a pericarditis. If you live in India or a developing world, the most common cause would be tuberculosis. We don't see too much tuberculosis here, but as I mentioned, after a viral illness would be the most common.

Allan Klein, MD:

And then you have a non-infectious causes and probably the most common cause would be post-cardiac injury syndrome. That includes if you have open heart surgery, let's say valve replacement, aorta surgery, valve repair. You can sometimes get pericarditis from that. Also, after for example, electrophysiologic procedures, an AFib ablation, a VT ablation, you may get pericarditis.

Allan Klein, MD:

Other causes that we would see would be autoimmune, such as lupus, rheumatoid arthritis can cause pericarditis, and finally neoplastic disease. If there's cancer, sometimes that can invade the pericardium and you would get pericarditis.

Allan Klein, MD:

What are some of the risk factors for developing what we call complicated pericarditis? Complicated pericarditis means that after the acute episodes, you get recurrent pericarditis, which occurs in a third of the patients. Roughly 6% of patients have multiple recurrences and some patients have colchicine-resistant, steroid-dependent and some develop constrictive pericarditis. So this complicated pericarditis is what we see here at Cleveland Clinic and we try to treat that accordingly.

Allan Klein, MD:

In terms of the treatment and management, we use the European Society of Cardiology Guidelines, and that's a stepwise approach. So if you have acute or recurrent pericarditis, the first line would be NSAIDs, such as ibuprofen or Naproxen or aspirin with colchicine.

Allan Klein, MD:

The second line, if you fail the first line, then often you go to low dose steroids as in prednisone. That combination is called triple therapy, NSAID, colchicine and prednisone. We tell the patients to restrict their exercise because exercise is good for the heart in general, but bad for the inflamed pericardium.

Allan Klein, MD:

Then third line would be things like biologics, Anakinra, rilonacept, IVIG, methotrexate or azathioprine, and the fourth line would be pericardiectomy. This is now changing because of the new advances in therapeutics. I like to mention the two advances would be, for example, the interleukin blockers. Similar to when you have allergies, you take antihistamines, with pericarditis, you get inflammation and you get increased production of the interleukin pathway. Interleukin 1 alpha and beta. And now we have targeted therapy, including Anakinra, which is a biologic, as well as rilonacept.

Allan Klein, MD:

We did a very important trial in the last year called the RHAPSODY trial, not Bohemian Rhapsody, but just regular rhapsody. And that was presented as a late-breaking trial of the American Heart Association and published online in the New England Journal of Medicine. And this led to the approval of the rilonacept by the FDA in March of this year so now that you have a FDA-approved therapeutics for recurrent pericarditis, and people are coming here to get put on this proper therapy.

Allan Klein, MD:

The outlook is quite good for recurrent pericarditis if you catch it early. The biggest mistake that we see here is that the acute episode is not recognized properly and when recognized it's undertreated and patients come here with multiple recurrent pericarditis episodes. They're often stuck on the prednisone. They can't get off the colchicine, and then when they come here, we could take a good history and examine the patient, but we would do our advanced imaging, try to figure out how advanced it is or how acute it is and recommend the proper therapy.

Allan Klein, MD:

Now, one thing that I should mention is that the MRI is very, very useful because it can prognosticate how bad the severity is and how many months to years you may need to be put on therapy.

Allan Klein, MD:

Let me mention very briefly about COVID and the vaccination. So COVID itself, COVID 19 can affect the lungs and it does affect the heart and can cause a mild pericarditis inflammation of the muscle, or the lining. It's not that common. It's probably less than 10% incidence.

Allan Klein, MD:

Another important point is that now the mRNA vaccines such as with Pfizer and Moderna, can rarely cause myocarditis or mild pericarditis. The phenotype or a certain person that gets this would be a young 20-year old male that has a lot of testosterone and testosterone may play some role, and they can get a myocarditis, pericarditis. Usually, this is very self-limited, very self-limited and goes away over time. And the treatment is very, very similar to treating recurrent pericarditis from other causes.

Allan Klein, MD:

So in summary, I think there's a lot of excitement in this field. Pericarditis, as I mentioned, we have the advanced imaging and new therapeutics in treating this problematic disease. Thank you very much.

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