Cremer Paul C, Klein Allan L, Imazio Massimo
Division of Cardiology, Bluhm Cardiovascular Institute, Departments of Medicine and Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland, Ohio.
JAMA. 2024 Oct 1;332(13):1090-1100. doi: 10.1001/jama.2024.12935.
Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. With appropriate treatment, 70% to 85% of these patients have a benign course. In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening.
Acute pericarditis is diagnosed with presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine (≈90%); new widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%); a new or increased pericardial effusion that is most often small (≈60%); or a pericardial friction rub (<30%). In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations. Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis. Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%). With a first recurrence of pericarditis, colchicine should be continued for at least 6 months. Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine. In certain patients with multiple recurrences, which can occur for several years, interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids.
Acute pericarditis is a common cause of nonischemic chest pain. Tuberculosis is the leading cause of pericarditis in endemic areas and is treated with antitubercular therapy. In North America and Western Europe, pericarditis is typically idiopathic, develops after a viral infection, or develops following cardiac procedures or surgery. Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence. Patients with multiple recurrent pericarditis can have a disease duration of several years or more, are often treated with corticosteroids, and IL-1 blockers may be used for selected patients as steroid-sparing therapy.
在北美和西欧，心包炎占非缺血性胸痛急诊就诊病例的比例高达5%。经过适当治疗，这些患者中70%至85%病程呈良性。在急性心包炎中，缩窄性心包炎（<0.5%）和心包填塞（<3%）的发生可能危及生命。
急性心包炎的诊断需具备以下2项或更多表现：尖锐的、胸膜炎性胸痛，仰卧时加重（约90%）；新出现的广泛心电图ST段抬高和PR段压低（约25% - 50%）；新出现或增多的心包积液，多数情况下积液量较小（约60%）；或心包摩擦音（<30%）。在北美和西欧，急性心包炎最常见的病因是特发性或病毒性，其次是心脏手术或操作后的心包炎。在流行地区，结核病是最常见的病因，采用抗结核治疗，对于合并缩窄性心包炎的患者可考虑使用皮质类固醇。急性特发性心包炎以及心脏手术或操作后的心包炎的治疗包括使用高剂量非甾体抗炎药（NSAIDs），一旦胸痛缓解且C反应蛋白水平恢复正常，通常在数周内逐渐减量。这些患者应接受为期3个月的秋水仙碱治疗，以缓解症状并降低复发风险（37.5%对16.7%；绝对风险降低20.8%）。心包炎首次复发时，秋水仙碱应至少持续使用6个月。如果心包炎使用NSAIDs和秋水仙碱治疗效果不佳，常使用皮质类固醇。在某些多次复发（可持续数年）的患者中，白细胞介素1（IL - 1）阻滞剂已显示出疗效，可能比皮质类固醇更受青睐。
急性心包炎是非缺血性胸痛的常见病因。结核病是流行地区心包炎的主要病因，采用抗结核治疗。在北美和西欧，心包炎通常为特发性，在病毒感染后发生，或在心脏手术或手术后发生。NSAIDs和秋水仙碱治疗使大多数患者预后良好，尽管15%至30%的患者会复发。多次复发性心包炎患者的病程可能持续数年或更长，常采用皮质类固醇治疗，对于特定患者，IL - 1阻滞剂可作为减少类固醇使用的治疗方法。
