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Corticosteroid therapy for pericarditis: a double-edged sword

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 118–119 (2008)Cite this article

Acute pericarditis is recorded in about 5% of patients admitted to emergency departments in Western Europe and the US for nonischemic chest pain, and recurs in approximately 30% of cases.1,2,3 In developed countries, 80–85% of cases reported in major clinical surveys with unselected patients and a traditional diagnostic approach are labeled idiopathic.4,5 The etiology of pericarditis in these patients is frequently presumed to be viral or autoimmune. In cases such as these, aspirin and NSAIDs are the mainstay of treatment, and are a class I recommendation in European guidelines.6 Although guidelines and reviews recommend limiting the use of corticosteroids, they are currently administered to 60–90% of patients in most series.7 Corticosteroids might have a specific indication in rare, selected cases, with a definite rheumatologic etiology, during pregnancy, or in cases of aspirin and NSAID failure, intolerance, or contraindication. In such cases high doses (e.g. prednisone 1.0–1.5 mg/kg/day) have been recommended.6,8 Corticosteroids are initially very effective, but they are often tapered too quickly and the side effects associated with these drugs, as well as relapses of pericarditis, are common. One of the most problematic issues in pericardial diseases is, therefore, how to manage a patient with corticosteroid-dependence.1,3 We recommend a cautious approach to the use of corticosteroids in patients with acute pericarditis, particularly if the etiology is unknown. Here we discuss the weak evidence-base for the use of these agents and their known side effects, and propose a treatment strategy for use in the minority of cases where corticosteroids are indicated.

Only one retrospective study8 has supported the use of high doses of corticosteroids in patients with idiopathic recurrent pericarditis. In this study, 12 patients were treated with a 3-month course of prednisone, receiving 1.0–1.5 mg/kg/day for 1 month with subsequent gradual tapering. Patients then commenced a 5-month course of aspirin at 1.6 g/day until prednisone had been completely withdrawn, at which point the aspirin dose was reduced to 0.8 g/day. Treatment resulted in stable remission in all but one patient. The long course of aspirin could partially explain the observed positive results.

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  1. The authors' affiliations and biographies are available on the Nature Clinical Practice Cardiovascular Medicine website.

Authors and Affiliations

  1. Cardiac Rehabilitation Institute, Sheba Medical Center and Sackler University, Tel-Hashomer, Israel

    Yehuda Adler

Authors
  1. Massimo Imazio
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  2. Antonio Brucato
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  3. Rita Trinchero
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  4. Ralph Shabetai
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  5. David Spodick
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  6. Yehuda Adler
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Correspondence to Yehuda Adler.

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The authors declare no competing financial interests.

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Imazio, M., Brucato, A., Trinchero, R. et al. Corticosteroid therapy for pericarditis: a double-edged sword. Nat Rev Cardiol 5, 118–119 (2008). https://doi.org/10.1038/ncpcardio1094

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