Pericarditis resident survival guide: Difference between revisions
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Causes|Causes]] | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Causes|Causes]] | ||
|- | |- | ||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide# | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]] | ||
|- | |||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Complete Diagnostic Approach to Acute Pericarditis|Complete Diagnostic Approach]] | |||
|- | |- | ||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Treatment|Treatment]] | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Treatment|Treatment]] | ||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Don'ts|Don'ts]] | ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pericarditis resident survival guide#Don'ts|Don'ts]] | ||
|} | |} | ||
==Overview== | ==Overview== | ||
[[Pericarditis]] is the inflammation of the fibroelastic sac surrounding the [[heart]] ([[pericardium]]). Pericarditis is | [[Pericarditis]] is the inflammation of the fibroelastic sac surrounding the [[heart]] ([[pericardium]]). Pericarditis is classified either as either acute (<6 weeks), subacute (6 weeks to 6 months) or chronic (>6 months) in duration and it can be further classified as either dry, fibrinous or effusive. [[Myopericarditis]], or [[perimyocarditis]] refers to acute pericarditis associated with myocardial inflammation that leads to global or regional myocardial dysfunction and elevation in the concentration of [[troponin|troponins]], [[creatine kinase|creatine kinase MB]], [[myoglobin]] and [[tumour necrosis factor]].<ref name="pmid22450720">{{cite journal| author=Imazio M| title=Contemporary management of pericardial diseases. | journal=Curr Opin Cardiol | year= 2012 | volume= 27 | issue= 3 | pages= 308-17 | pmid=22450720 | doi=10.1097/HCO.0b013e3283524fbe | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22450720 }} </ref> [[Pericarditis]] should be suspected in the presence of [[pleuritic chest pain]] that is positional along with a [[pericardial friction rub]]. [[NSAIDs]] are the mainstay of the treatment of [[acute pericarditis]]; [[ibuprofen]] is administered most often.<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref> | ||
==Causes== | ==Causes== | ||
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* Viral: [[Adenovirus]], [[CMV]], [[coxsackie]], [[EBV]], [[echovirus]], [[HBV]], [[HIV]], [[herpes|human herpes virus 6]], [[influenza]], [[mumps]], [[parvovirus B19]], [[rubella]], [[varicella]]<ref name="pmid20177006">{{cite journal| author=Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y| title=Controversial issues in the management of pericardial diseases. | journal=Circulation | year= 2010 | volume= 121 | issue= 7 | pages= 916-28 | pmid=20177006 | doi=10.1161/CIRCULATIONAHA.108.844753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20177006 }} </ref> | * Viral: [[Adenovirus]], [[CMV]], [[coxsackie]], [[EBV]], [[echovirus]], [[HBV]], [[HIV]], [[herpes|human herpes virus 6]], [[influenza]], [[mumps]], [[parvovirus B19]], [[rubella]], [[varicella]]<ref name="pmid20177006">{{cite journal| author=Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y| title=Controversial issues in the management of pericardial diseases. | journal=Circulation | year= 2010 | volume= 121 | issue= 7 | pages= 916-28 | pmid=20177006 | doi=10.1161/CIRCULATIONAHA.108.844753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20177006 }} </ref> | ||
Click '''[[Pericarditis causes|here]]''' for the complete list of causes. | |||
{| | ==FIRE: Focused Initial Rapid Evaluation== | ||
| | A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref> | ||
< | <span style="font-size:85%">Boxes in red color signify that an urgent management is needed.</span> | ||
<span style="font-size:85%">'''Abbreviations:''' '''ECG:''' electrocardiogram</span> | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{ | {{familytree | | | | | | D01 | | | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute pericarditis'''<br> | ||
<div | ❑ Characteristic [[chest pain]]<br> | ||
:❑ Sharp and pleuritic that is improved by sitting up and leaning forward | |||
< | ❑ [[Pericardial friction rub]] <BR> | ||
:❑ High pitched, scratchy sound at the left sternal border best heard with the diaphragm of the stethoscope | |||
:❑ Heard during [[atrial systole]], [[ventricular systole]] and rapid ventricular filling in early [[diastole]] | |||
❑ Suggestive [[ECG]] changes <br> | |||
:❑ Diffuse [[ST elevation]] with reciprocal [[ST depression]] in leads aVR and V1 | |||
</div>}} | </div>}} | ||
{{ | {{familytree | | | | | | |!| | | | | | | | | | }} | ||
{{ | {{familytree | | | | | | E01 | | | | | | | | | E01=<div style="float: left; text-align: left; padding:1em;"> '''Does the patient have the following clinical findings suggestive of [[cardiac tamponade]]?'''<br> | ||
<div | ❑ [[Sinus tachycardia]] <BR> | ||
❑ [[Hypotension]] <BR> | |||
< | ❑ [[Jugular vein distention]]<br> | ||
❑ [[Muffled heart sounds]]<br> | |||
❑ [[Pulsus paradoxus]] <BR></div>}} | |||
<div | {{familytree | | | | |,|-|^|-|.| | | | |}} | ||
{{ | {{familytree | | | |B01 | | B02 | | | | B01=<div style="text-align: center; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}}</div> | B02= '''No'''|boxstyle_B01= background-color: #FA8072}} | ||
</ | {{familytree | | | | |!| | | |!| | | | }} | ||
{{familytree | | | |C01 | | C02 | | | | C01=<div style="float: left; text-align: left; padding:1em;"> {{fontcolor|#F8F8FF| | |||
❑ Order (urgent): | |||
:❑ [[Chest X-ray|<span style="color:white;">Chest X-ray </span>]] | |||
{{ | :❑ [[Echocardiography|<span style="color:white;">2-D and Doppler echocardiography</span>]] | ||
❑ Immediately transfer the patient to ICU <BR> | |||
❑ Monitor telemetry and check vitals frequently<br>}}</div> |C02=<div style="float: left; text-align: left; padding:1em;"> '''[[Pericarditis resident survival guide#Complete Diagnostic Approach to Acute Pericarditis|Continue with the complete diagnostic approach below]]''' </div>|boxstyle_C01= background-color: #FA8072}} | |||
{{ | {{familytree | | | | |!| | | | | | | | }} | ||
<div | {{familytree | | | |D01 | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;"> {{fontcolor|#F8F8FF| '''Indications for pericardiocentesis:''' | ||
❑ Findings suggestive of unstable [[cardiac tamponade|<span style="color:white;">cardiac tamponade</span>]]: | |||
| | :❑ Collapse of the cardiac chamber | ||
:❑ Respiratory variation in chamber size | |||
{{fontcolor|#F8F8FF|No}} </div> | :❑ Respiratory variation in transvalvular velocities | ||
:❑ Dilated IVC and hepatic veins | |||
{{ | :❑ Click here for '''[[Cardiac tamponade resident survival guide|<span style="color:white;">cardiac tamponade resident survival guide</span>]]''' | ||
<div | ❑ Effusions > 20 mm in [[echocardiography|<span style="color:white;">echocardiography</span>]] in diastole<br> | ||
❑ High suspicion of purulent or neoplastic [[pericarditis|<span style="color:white;">pericarditis</span>]]<br> | |||
| | ❑ Large symptomatic effusion despite medical treatment for > 1 week<br>}} </div>|boxstyle_D01= background-color: #FA8072}} | ||
{{familytree | | | | |!| | | | | | | | }} | |||
{{familytree | | | |E01 | | | | | | | E01=<div style="float: left; text-align: left; padding:1em; background: #FA8072;"> {{fontcolor|#F8F8FF| '''Does the patient have any absolute contraindication for pericardiocentesis:''' | |||
❑ [[Aortic dissection|<span style="color:white;">Aortic dissection</span>]]<br> | |||
❑ Distorted anatomy due to prior surgery or radiation therapy<br> | |||
❑ Inaccessibility of the heart by percutaneous drainage<br>}} </div>|boxstyle_E01= background-color: #FA8072}} | |||
| | {{familytree | | |,|-|^|-|.| | | | | | }} | ||
{{ | {{familytree | | F01 | | F02 | | | | | F01=<div style="text-align: center; padding:1em;"> {{fontcolor|#F8F8FF|'''No'''}}</div>|F02=<div style="text-align: center; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}}</div>|boxstyle= background-color: #FA8072}} | ||
| | {{familytree | | |!| | | |!| | | | }} | ||
<div | {{familytree | | G01 | | G02 | | | G01=<div style="float: left; text-align: left; padding:1em; text-align: left"> {{fontcolor|#F8F8FF| '''Perform pericardiocentesis:''' | ||
❑ Subxiphoid approach (most preferred) <br> | |||
❑ Avoid the subcostal approach if coagulopathy is present to prevent life-threatening hepatic injury <br> | |||
❑ Drain fluid < 1 L at a time (to prevent sudden decompression syndrome) <br> | |||
❑ Relative contraindications:<br> | |||
:❑ Uncorrected coagulopathy | |||
:❑ Anticoagulant therapy | |||
:❑ Thrombocytopenia < 50,000/mm³ | |||
:❑ Small (< 1cm in echo), posterior and loculated effusion | |||
:❑ Severe [[pulmonary hypertension|<span style="color:white;">pulmonary hypertension</span>]] | |||
❑ Discontinue [[anticoagulation|<span style="color:white;">anticoagulation</span>]] drugs and initiate [[FFP|<span style="color:white;">FFP</span>]] if there is high INR<br> | |||
❑ [[Myocardial rupture|<span style="color:white;">Myocardial rupture</span>]]: Rescue [[pericardiocentesis|<span style="color:white;">pericardiocentesis</span>]] may be done before surgical drainage<br> | |||
❑ Perform [[pericardiocentesis|<span style="color:white;">pericardiocentesis</span>]] in the operating room before surgery, when surgical drainage is indicated but the patient has severe [[hypotension|<span style="color:white;">hypotension</span>]] prohibiting the induction of [[anesthesia|<span style="color:white;">anesthesia</span>]] <ref name="pmid23376916">{{cite journal| author=Schiavone WA| title=Cardiac tamponade: 12 pearls in diagnosis and management. | journal=Cleve Clin J Med | year= 2013 | volume= 80 | issue= 2 | pages= 109-16 | pmid=23376916 | doi=10.3949/ccjm.80a.12052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23376916 }} </ref>}} </div>| G02=<div style="float: left; text-align: left; padding:1em; width:22em; text-align: left"> {{fontcolor|#F8F8FF| '''Perform surgical drainage:''' | |||
❑ Also more appropriate for:<br> | |||
:❑ [[Myocardial rupture|<span style="color:white;">Myocardial rupture</span>]] <br> | |||
:❑ Acute traumatic hemopericardium <br> | |||
:❑ Purulent [[pericarditis|<span style="color:white;">pericarditis</span>]] <br> | |||
:❑ Reaccumulation after [[pericardiocentesis|<span style="color:white;">pericardiocentesis</span>]] <br>}}</div>|boxstyle= background-color: #FA8072}} | |||
{{familytree | | |`|-|v|-|'| | | | }} | |||
{{familytree | | | | H01 | | | | | | H01=<div style="float: left; text-align: left; padding:1em;"> '''[[Pericarditis resident survival guide#Complete Diagnostic Approach to Acute Pericarditis|After the stabilization of the patient, continue with the complete diagnostic approach below]]''' </div> | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Pericarditis resident survival guide#Complete Diagnostic Approach to Acute Pericarditis|Continue with the complete diagnostic approach below]]''' </div>}} | |||
{{Family tree/end}} | {{Family tree/end}} | ||
==Complete Diagnostic Approach to Acute Pericarditis== | |||
| | A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid23998693">{{cite journal| author=Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B et al.| title=American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 965-1012.e15 | pmid=23998693 | doi=10.1016/j.echo.2013.06.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998693 }} </ref><ref name="pmid15548780">{{cite journal |author=Lange RA, Hillis LD |title=Clinical practice. Acute pericarditis |journal=[[N. Engl. J. Med.]] |volume=351 |issue=21 |pages=2195–202 |year=2004 |month=November |pmid=15548780 |doi=10.1056/NEJMcp041997 |url=}}</ref> | ||
< | <span style="font-size:85%"> '''Abbreviations:''' '''TDS:''' three times a day; '''QID:''' four times a day; '''wk:''' week </span> | ||
==Characterize the symptoms | {{Family tree/start}} | ||
{{Family tree| | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Characterize the symptoms:'''<br> | |||
❑ [[Chest pain]] | ❑ [[Chest pain]] | ||
:❑ Sudden onset | :❑ Sudden onset | ||
:❑ Sharp or dull, aching and pressure like | :❑ Sharp or dull, aching and pressure like | ||
:❑ Pleuritic (exacerbated by [[inspiration]] and [[coughing]]) | :❑ Pleuritic (exacerbated by [[inspiration]] and [[coughing]]) | ||
:❑ Retrosternal | :❑ Retrosternal | ||
:❑ | :❑ Located in the [[trapezius]] muscle ridge | ||
:❑ Radiation to the neck or the arms | |||
:❑ Affected by position (improved by sitting up and leaning forward)<br> | :❑ Affected by position (improved by sitting up and leaning forward)<br> | ||
:❑ No pain ([[uremia]] and [[tuberculosis]] pericarditis develop slowly)<br> | :❑ No pain ([[uremia]] and [[tuberculosis]] pericarditis develop slowly)<br> | ||
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❑ [[Joint pains]] (suggestive of autoimmune etiology)<br> | ❑ [[Joint pains]] (suggestive of autoimmune etiology)<br> | ||
❑ [[Odynophagia]] <br> | ❑ [[Odynophagia]] <br> | ||
❑ [[Weight loss]] (suggestive of malignant etiology) | ❑ [[Weight loss]] (suggestive of malignant etiology) </div>}} | ||
{{Family tree| | | | | | | |!| | | | | | }} | |||
</div> | {{Family tree| | | | | | | B01 | | | | | B01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Obtain a detailed history:'''<br> | ||
<div | |||
❑ Infections | ❑ Infections | ||
:❑ [[Pneumonia]] | :❑ [[Pneumonia]] | ||
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::❑ Travel to Central or South America ([[Chagas disease]]) | ::❑ Travel to Central or South America ([[Chagas disease]]) | ||
::❑ Travel to Central Asia or South Africa or South America ([[Tuberculosis]])<ref name="pmid23968879">{{cite journal| author=| title=WHO launches World health report 2013. | journal=Euro Surveill | year= 2013 | volume= 18 | issue= 33 | pages= 20559 | pmid=23968879 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23968879 }} </ref> | ::❑ Travel to Central Asia or South Africa or South America ([[Tuberculosis]])<ref name="pmid23968879">{{cite journal| author=| title=WHO launches World health report 2013. | journal=Euro Surveill | year= 2013 | volume= 18 | issue= 33 | pages= 20559 | pmid=23968879 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23968879 }} </ref> | ||
::❑ Travel to North and Central America | ::❑ Travel to North and Central America, such as Ohio and Mississippi River valleys ([[Histoplasmosis]]) | ||
::❑ Travel to North America ([[Blastomycosis]]) <br> | ::❑ Travel to North America ([[Blastomycosis]]) <br> | ||
❑ [[Pericarditis causes#Causes by Organ System|Medications]] | ❑ [[Pericarditis causes#Causes by Organ System|Medications]] | ||
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:❑ [[Dressler's syndrome]] | :❑ [[Dressler's syndrome]] | ||
:❑ [[Postpericardiotomy syndrome]] | :❑ [[Postpericardiotomy syndrome]] | ||
:❑ [[chest trauma|Trauma history]] | :❑ [[chest trauma|Trauma history]] </div>}} | ||
{{Family tree| | | | | | | |!| | | | | | }} | |||
</div> | {{Family tree| | | | | | | C01 | | | | | C01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Examine the patient:'''<br> | ||
'''Vital signs''' <br> | |||
<div | ❑ [[Pulse]] | ||
:❑ [[Tachycardia]] (typical) | |||
:❑ [[Bradycardia]] (in [[hypothyroidism]] and [[uremia]]) | |||
:❑ [[Pulsus paradoxus]] (in [[cardiac tamponade]]) | |||
❑ [[Blood pressure]] | |||
:❑ Normal (typical) | |||
:❑ [[Hypotension]] (in [[cardiac tamponade]]) | |||
❑ [[Temperature]] | |||
:❑ [[Fever]] less than 39°C or 102.2°F | |||
:❑ [[Hypothermic]] (in elderly and [[renal failure]]) | |||
❑ [[Respiratory rate]] | |||
:❑ [[Tachypnea]] (typical) | |||
'''Cardiovascular system''' <br> | '''Cardiovascular system''' <br> | ||
'''Auscultation''' <br> | '''Auscultation''' <br> | ||
❑ Heart sounds | |||
:❑ Normal (typical) | |||
:❑ New [[S3]] heart sound | |||
:❑ Distant and muffled (in [[cardiac tamponade]]) | |||
❑ [[Murmur]] (in concomitant heart disease)<br> | |||
❑ [[Pericardial friction rub]] | |||
:❑ High pitched, scratchy or squeaky sound | |||
:❑ Best heard at the left sternal border | |||
:❑ Best heard with the diaphragm of the stethoscope | |||
:❑ Varies in intensity overtime and needs repeated examinations | |||
<center>{{#ev:youtube|watch?v=EUCp_3_vwtw|300}}</center> | <center>{{#ev:youtube|watch?v=EUCp_3_vwtw|300}}</center> | ||
'''Palpation''' <br> | '''Palpation''' <br> | ||
❑ [[Jugular venous pulse]] | |||
:❑ Elevated (in [[cardiac tamponade]] and [[constrictive pericarditis]]) <br> | |||
:❑ [[Kussmaul sign]] (in [[constrictive pericarditis]]) <br> | |||
'''Percussion''' <br> | '''Percussion''' <br> | ||
❑ Cardiac dullness beyond the apical point of maximal impulse (in [[pericardial effusion]]) <br> | |||
'''Respiratory system''' <br> | |||
''' | |||
❑ [[Wheeze]] or [[rales]]<br> | |||
❑ [[Pleural effusion]]<br> | |||
< | |||
'''Abdomen''' | |||
❑ Pulsatile [[hepatomegaly]] (in [[constrictive pericarditis]]) <br> | |||
❑ [[Ascites]] </div>}} | |||
{{Family tree| | | | | | | |!| | | | | | }} | |||
{{Family tree| | | | | | | D01 | | | | | D01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Order tests (Urgent):''' <br><br> | |||
'''Order laboratory tests (urgent):'''<br> | '''Order laboratory tests (urgent):'''<br> | ||
❑ [[Complete blood count|CBC]] ([[leucocytosis]]) <br> | ❑ [[Complete blood count|CBC]] ([[leucocytosis]]) <br> | ||
❑ [[ESR]] (elevated) <BR> | ❑ [[ESR]] (elevated) <BR> | ||
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::❑ Right atrial collapse | ::❑ Right atrial collapse | ||
::❑ Diastolic collapse of [[right ventricle]] and [[left atrium]] (specific for cardiac tamponade) | ::❑ Diastolic collapse of [[right ventricle]] and [[left atrium]] (specific for cardiac tamponade) | ||
:❑ Check for concomitant [[heart disease]] or paracardial pathology</div> | :❑ Check for concomitant [[heart disease]] or paracardial pathology </div>}} | ||
{{Family tree| | | | | | | |!| | | | | | }} | |||
<div | {{Family tree| | | | | | | E01 | | | | | E01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Does the patient have at least two of the following criteria for the diagnosis of acute pericarditis?'''<br> | ||
❑ Characteristic [[chest pain]] <br> | ❑ Characteristic [[chest pain]] <br> | ||
:❑ Sharp and pleuritic that is improved by sitting up and leaning forward | :❑ Sharp and pleuritic that is improved by sitting up and leaning forward | ||
❑ [[Pericardial friction rub]] <BR> | ❑ [[Pericardial friction rub]] <BR> | ||
:❑ High pitched, scratchy sound at the left sternal border best heard with diaphragm of the stethoscope | :❑ High pitched, scratchy sound at the left sternal border best heard with the diaphragm of the stethoscope | ||
:❑ Heard during [[atrial systole]], [[ventricular systole]] and rapid ventricular filling | :❑ Heard during [[atrial systole]], [[ventricular systole]] and rapid ventricular filling in early [[diastole]] | ||
❑ Suggestive | ❑ Suggestive [[ECG]] changes <br> | ||
:❑ Diffuse [[ST elevation]] with reciprocal [[ST depression]] in leads aVR and V1 | :❑ Diffuse [[ST elevation]] with reciprocal [[ST depression]] in leads aVR and V1 | ||
❑ Suggestive [[echocardiography]] changes <br> | ❑ Suggestive [[echocardiography]] changes <br> | ||
:❑ New or worsening [[pericardial effusion]] | :❑ New or worsening [[pericardial effusion]] </div>}} | ||
{{Family tree| | | |,|-|-|-|^|-|-|-|.| | }} | |||
{{Family tree| | | F01 | | | | | | F02 | F01= Yes| F02= No}} | |||
{{Family tree| | | |!| | | | | | | |!| | }} | |||
{{Family tree| | | G01 | | | | | | G02 | | G01= <div style="float: left; text-align: left; width:15em; padding:1em;">'''Does the patient have any sign of myocarditis?'''<br> | |||
❑ Elevated [[cardiac enzymes]], or <BR>❑ Global or regional myocardial dysfunction on echocardiography | ❑ Elevated [[cardiac enzymes]], or <BR>❑ Global or regional myocardial dysfunction on [[echocardiography]] </div>| G02= <div style="float: left; text-align: left; width:15em; padding:1em;">'''Does the patient have any signs suspicious of acute pericarditis?'''<br> | ||
</div> | |||
<div | |||
❑ Ongoing [[fever]] <BR> | ❑ Ongoing [[fever]] <BR> | ||
❑ Poor response to treatment<br> | ❑ Poor response to treatment<br> | ||
❑ Hemodynamic compromise< | ❑ Hemodynamic compromise </div>}} | ||
{{Family tree| |,|-|^|-|.| | | |,|-|^|-|.| | }} | |||
|} | {{Family tree| H01 | | H02 | | H03 | | H04 | H01= No| H02= Yes| H03= No| H04= Yes}} | ||
{{Family tree| |!| | | |!| | | |!| | | |!| | }} | |||
{{Family tree| I01 | | I02 | | I03 | | I04 | I01= [[Acute pericarditis]]| I02= [[Myopericarditis]]| I03= <div style="float: left; text-align: left; width:15em; padding:1em;">Consider [[Pericarditis differential diagnosis|alternative diagnosis]] and treat accordingly </div>| I04= Consider cardiac MRI (CMR)<ref name="pmid20511488">{{cite journal |author=Khandaker MH, Espinosa RE, Nishimura RA, ''et al.'' |title=Pericardial disease: diagnosis and management |journal=Mayo Clinic Proceedings. Mayo Clinic |volume=85 |issue=6 |pages=572–93 |year=2010 |month=June |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref>}} | |||
{{Family tree| | | | | | | | | | | | | |!| | }} | |||
{{Family tree| | | | | | | | | | | | | J01 | J01= <div style="float: left; text-align: left; width:15em; padding:1em;">Treat as [[acute pericarditis]] or [[myopericarditis]] if there is delayed enhancement on CMR </div>}} | |||
{{Family tree/end}} | |||
==Treatment== | ==Treatment== | ||
===Treatment of Acute Pericarditis=== | ===Treatment of Acute Pericarditis=== | ||
Shown below is an algorithm summarizing the management of [[acute pericarditis]] in adults.<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid23998693">{{cite journal| author=Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B et al.| title=American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 965-1012.e15 | pmid=23998693 | doi=10.1016/j.echo.2013.06.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998693 }} </ref><ref name="pmid15548780">{{cite journal |author=Lange RA, Hillis LD |title=Clinical practice. Acute pericarditis |journal=[[N. Engl. J. Med.]] |volume=351 |issue=21 |pages=2195–202 |year=2004 |month=November |pmid=15548780 |doi=10.1056/NEJMcp041997 |url=}}</ref> | Shown below is an algorithm summarizing the management of [[acute pericarditis]] in adults.<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid23998693">{{cite journal| author=Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B et al.| title=American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 965-1012.e15 | pmid=23998693 | doi=10.1016/j.echo.2013.06.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998693 }} </ref><ref name="pmid15548780">{{cite journal |author=Lange RA, Hillis LD |title=Clinical practice. Acute pericarditis |journal=[[N. Engl. J. Med.]] |volume=351 |issue=21 |pages=2195–202 |year=2004 |month=November |pmid=15548780 |doi=10.1056/NEJMcp041997 |url=}}</ref> | ||
<span style="font-size:85%">'''Abbreviations:''' '''CRP:''' C-reactive protein; '''MI:''' Myocardial infarction</span> | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{ | {{Family tree| | | | | | | | | | A01 | | | | | A01=<div style="text-align: left; width:22em; padding:1em;"> '''Does the patient have any of the following high risk features?''' <br> | ||
❑ [[Fever]] >38°C <br> | ❑ [[Fever]] >38°C <br> | ||
❑ [[Leucocytosis]] <BR> | ❑ [[Leucocytosis]] <BR> | ||
Line 346: | Line 326: | ||
❑ [[Immunosuppression|Immunosuppressed state]] <br> | ❑ [[Immunosuppression|Immunosuppressed state]] <br> | ||
❑ Acute [[trauma]] <br> | ❑ Acute [[trauma]] <br> | ||
❑ Relapsing pericarditis | ❑ Relapsing pericarditis </div>}} | ||
</div>}} | {{Family tree| | | | | |,|-|-|-|-|^|-|-|-|-|.| }} | ||
{{ | {{Family tree| | | | | B01 | | | | | | | | B02 | B01= Yes| B02= No}} | ||
{{ | {{Family tree| | | | | |!| | | | | | | | | | | | }} | ||
{{ | {{Family tree| | | | | C01 | | | | | | | | C02 | C01= Inpatient treatment| C02= Outpatient treatment}} | ||
{{ | {{Family tree| |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | }} | ||
{{ | {{Family tree| D01 | | D02 | | D03 | | D04 | | D05 | D01=<div style="text-align: left; padding:1em;"> '''Unstable patient''' | ||
{{ | <br> | ||
❑ [[Cardiac tamponade]] <br> | ❑ [[Cardiac tamponade]] <br> | ||
:❑ [[Hypotension]] <BR> | :❑ [[Hypotension]] <BR> | ||
:❑ [[Pulsus paradoxus]] <br> | :❑ [[Pulsus paradoxus]] <br> | ||
:❑ [[Jugular vein distention]] | :❑ [[Jugular vein distention]]</div>| D02='''Stable [[Post myocardial infarction pericarditis|post MI]] patient'''| D03= '''Stable patient without prior [[MI]]''' | D04= '''[[Post myocardial infarction pericarditis|Post MI]]'''| D05= '''No previous MI'''}} | ||
{{ | {{Family tree| |!| | | |!| | | |!| | | |!| | | |!| | }} | ||
{{ | {{Family tree| E01 | | E02 | | E03 | | E04 | | E05 | E01=<div style="text-align: left; padding:1em;"> '''Treat [[cardiac tamponade]]'''<br> | ||
'''[[NSAIDs]]'''<br> | ❑ Click [[Cardiac tamponade resident survival guide|here]] for cardiac tamponade resident survival guide <BR> | ||
:❑ Immediately transfer the patient to ICU <BR> | |||
❑ [[Ibuprofen]] | :❑ Monitor telemetry and check vitals frequently<BR> | ||
:❑ Perform [[pericardiocentesis]] or surgical drainage<br> | |||
:❑ Orally 300-800 mg | ---- | ||
:❑ | '''Initiate medical therapy'''<br> | ||
❑ [[Indomethacin]] | '''''Administer [[NSAIDs]]'''''<br> | ||
:❑ Orally 50 mg | <span style="font-size:85%;color:red">Avoid NSAIDs in post-MI pericarditis</span><br> | ||
:❑ | ❑ [[Ibuprofen]] (first line)<br> | ||
:❑ Orally 300-800 mg TID or QID x 1-2 weeks<br> | |||
:❑ Taper gradually every 2-3 days, <br>OR <br> | |||
❑ [[Indomethacin]] <br> | |||
:❑ Orally 50 mg TID x 1-2 weeks<br> | |||
:❑ Taper gradually every 2-3 days for Rx period of 3-4 weeks<br> | |||
<br>'''OR'''<br> | |||
'''[[ | '''''Administer [[aspirin]]'''''<br> | ||
❑ Drug of choice in | ❑ Drug of choice in [[Dressler's syndrome|post-MI pericarditis]] patients <br> | ||
❑ [[aspirin|High-dose aspirin]]: <br> | ❑ [[aspirin|High-dose aspirin]]: <br> | ||
:❑ Orally 800 mg QID | :❑ Orally 800 mg TID or QID x 7-10 days <BR> | ||
:❑ | :❑ Taper gradually by 800 mg/week for 3 additional weeks <br> | ||
❑ Stop [[anticoagulants]] if patient develops [[pericardial effusion]] <br> | ❑ Stop [[anticoagulants]] if patient develops [[pericardial effusion]] <br> | ||
<br> '''AND/OR''' <br> | |||
'''[[ | '''''Administer [[colchicine]]'''''<br> | ||
❑ Combination with [[NSAIDs]] (better response rate)<ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br> | ❑ Combination with [[NSAIDs]] (better response rate)<ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br> | ||
❑ Can be used alone<BR> | ❑ Can be used alone<BR> | ||
Line 386: | Line 373: | ||
''' | '''''Administer gastroprotective agents'''''<br> | ||
❑ [[Misoprostol]] (600 to 800 mg/day)<BR> | ❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR> | ||
❑ [[Omeprazole]] (20 mg/day) <br> | ❑ [[Omeprazole]] (20 mg/day) <br> | ||
'''[[ | '''''Avoid [[steroids]]'''''<br> | ||
❑ Avoid steroids to treat an initial episode of pericarditis <br> | ❑ Avoid steroids to treat an initial episode of pericarditis <br> | ||
---- | ---- | ||
'''Order tests to identify the specific etiology'''<br> | '''Order tests to identify the specific etiology'''<br> | ||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Order specific tests based on the clinical suspicion]]<br> | |||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Treat according to the etiology]] | |||
---- | ---- | ||
❑ [[ | '''Educate about life style modification'''<br> | ||
❑ [[ | ❑ In case of [[pericarditis]], avoid strenuous physical activity until symptoms resolve<br> | ||
❑ In case of [[myopericarditis]], avoid competitive sports for six months and/or until normalization of lab findings | |||
</div>| E02=<div style="text-align: left; padding:1em;">'''Initiate medical therapy'''<br> | |||
'''''Administer [[aspirin|High-dose aspirin]]''''' <br> | |||
:❑ Orally 800 mg TID or QID x 7-10 days<BR> | |||
:❑ Taper gradually by 800 mg/week for 3 additional weeks <br> | |||
<br> '''AND/OR'''<br> | |||
'''''Administer [[Colchicine]]''''' <br> | |||
❑ In case of poor response to aspirin <ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br>❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR> | |||
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | |||
'''''Administer gastroprotective agents''''' <br> | |||
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR> | |||
:❑ [[Omeprazole]] (20 mg/day) <br> | |||
'''''Avoid [[NSAIDs]] ([[ibuprofen]])'''''<br> | |||
❑ Increase the risk of reinfarction<br> | |||
❑ Adversely impact left ventricular remodeling<br> | |||
❑ Block the effectiveness of [[aspirin]] <br> | |||
'''''Avoid [[steroids]]'''''<br> | |||
❑ Avoid steroids to treat an initial episode of pericarditis <br> | |||
❑ Stop [[anticoagulants]] if the patient develops [[pericardial effusion]] <br> | |||
---- | ---- | ||
'''Order | '''Order tests to identify the specific etiology'''<br> | ||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Order specific tests based on the clinical suspicion]]<br> | |||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Treat according to the etiology]] | |||
---- | ---- | ||
'''Educate about life style modification'''<br> | |||
❑ | ❑ In case of [[pericarditis]], avoid strenuous physical activity until symptoms resolve<br> | ||
❑ In case of [[myopericarditis]], avoid competitive sports for six months and/or until normalization of lab findings</div> | E03= | |||
❑ [[ | <div style="text-align: left; padding:1em;"> '''Initiate medical therapy'''<br> | ||
'''''Administer [[NSAIDs]] (First line)'''''<br> | |||
❑ [[Ibuprofen]] (first line)<br> | |||
'''Initiate medical therapy'''<br> | :❑ Orally 300-800 mg TID or QID x 1-2 weeks<br> | ||
:❑ Taper gradually every 2-3 days, OR <br> | |||
'''[[NSAIDs]]''' | ❑ [[Indomethacin]] <br> | ||
:❑ Orally 50 mg TID x 1-2 weeks<br> | |||
❑ [[Ibuprofen]] | :❑ Taper gradually every 2-3 days for Rx period of 3-4 weeks<br> | ||
:❑ Orally 300-800 mg | |||
:❑ | |||
❑ [[Indomethacin]] | |||
:❑ Orally 50 mg | |||
:❑ | |||
<br> '''AND/OR''' <br> | |||
'''[[Colchicine]] | '''''Administer [[Colchicine]]'''''<br> | ||
❑ Combination with [[NSAIDs]] (better response rate)<ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br> | ❑ Combination with [[NSAIDs]] (better response rate)<ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br> | ||
❑ Can be used alone<BR> | ❑ Can be used alone<BR> | ||
Line 440: | Line 440: | ||
''' | '''''Administer gastroprotective agents'''''<br> | ||
❑ [[Misoprostol]] (600 to 800 mg/day)<BR> | ❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<br> | ||
❑ [[Omeprazole]] (20 mg/day) <br> | ❑ [[Omeprazole]] (20 mg/day) <br> | ||
'''[[ | '''''Avoid [[steroids]]'''''<br> | ||
❑ Avoid steroids | ❑ Avoid steroids in an initial episode of pericarditis <br> | ||
---- | ---- | ||
'''Order tests to identify the specific etiology'''<br> | '''Order tests to identify the specific etiology'''<br> | ||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Order specific tests based on the clinical suspicion]]<br> | |||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Treat according to the etiology]] | |||
---- | ---- | ||
'''Order [[pericardiocentesis]] in case of '''<br> | |||
❑ [[ | ❑ High suspicion of purulent or neoplastic [[pericarditis]]<br> | ||
< | ❑ Effusions > 20 mm in [[echocardiography]] in [[diastole]]<br> | ||
❑ Large or symptomatic effusions despite one week of medical therapy | |||
---- | ---- | ||
'''[[aspirin|High-dose aspirin]]''' <br> | '''Educate about life style modification'''<br> | ||
:❑ Orally 800 mg QID | ❑ In case of [[pericarditis]], avoid strenuous physical activity until symptoms resolve<br> | ||
:❑ | ❑ In case of [[myopericarditis]], avoid competitive sports for six months and/or until normalization of lab findings | ||
❑ | </div>| E04= | ||
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR> | <div style="text-align: left; padding:1em;"> '''Initiate medical therapy'''<br> | ||
'''''Administer [[aspirin|High-dose aspirin]]''''' <br> | |||
:❑ Orally 800 mg TID or QID x 7-10 days<BR> | |||
:❑ Taper gradually by 800 mg/week for 3 additional weeks <br> | |||
<br> '''AND/OR'''<br> | |||
'''''Administer [[Colchicine]]''''' <br> | |||
❑ In case of poor response to aspirin <ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334 }} </ref> <br>❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR> | |||
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | |||
'''''Administer gastroprotective agents''''' <br> | |||
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR> | |||
:❑ [[Omeprazole]] (20 mg/day) <br> | :❑ [[Omeprazole]] (20 mg/day) <br> | ||
'''[[ | '''''Avoid [[NSAIDs]] ([[ibuprofen]])'''''<br> | ||
❑ May increase the risk of reinfarction<br> | |||
❑ May negatively impact left ventricular remodeling<br> | |||
❑ Associated with decreased effectiveness of [[aspirin]] <br> | |||
'''''Avoid [[steroids]]'''''<br> | |||
❑ Avoid steroids to treat an initial episode of pericarditis <br> | ❑ Avoid steroids to treat an initial episode of pericarditis <br> | ||
❑ Stop [[anticoagulants]] if the patient develops [[pericardial effusion]] <br> | |||
---- | ---- | ||
''' | '''Order tests to identify the specific etiology'''<br> | ||
❑ [[Pericarditis resident survival guide#Etiology Specific Management|Order specific tests based on the clinical suspicion]]<br> | |||
❑ | ❑ [[Pericarditis resident survival guide#Etiology Specific Management|Treat according to the etiology]] | ||
❑ | |||
---- | ---- | ||
'''NSAID's'''<br> | '''Educate about life style modification'''<br> | ||
❑ [[Ibuprofen]] | ❑ In case of [[pericarditis]], avoid strenuous physical activity until symptoms resolve<br> | ||
❑ In case of [[myopericarditis]], avoid competitive sports for six months and/or until normalization of lab findings | |||
</div>| E05= | |||
<div style="text-align: left; padding:1em;"> '''Initiate medical therapy'''<br> | |||
'''''Administer NSAID's'''''<br> | |||
❑ [[Ibuprofen]] <br> | |||
:❑ Preferred<br> | :❑ Preferred<br> | ||
:❑ Orally 300-800 mg | :❑ Orally 300-800 mg TID or QID x 1-2 weeks<br> | ||
:❑ | :❑ Taper gradually every 2-3 days, <br>OR <br> | ||
❑ [[Indomethacin]] | ❑ [[Indomethacin]] <br> | ||
:❑ Orally 50 mg | :❑ Orally 50 mg TID x 1-2 weeks<br> | ||
:❑ | :❑ Taper gradually every 2-3 days for Rx period of 3-4 weeks<br> | ||
<br> '''AND/OR'''<br> | |||
'''[[Colchicine]]'''<br> | '''[[Colchicine]]'''<br> | ||
Line 492: | Line 515: | ||
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | ❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | ||
'''''Administer gastroprotective agents''''' <br> | |||
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR> | |||
:❑ [[Omeprazole]] (20 mg/day) <br> | |||
'''[[ | '''''Avoid [[steroids]]'''''<br> | ||
❑ Avoid steroids to treat an initial episode of pericarditis <br> | ❑ Avoid steroids to treat an initial episode of pericarditis <br> | ||
---- | ---- | ||
''' | '''Educate about life style modification'''<br> | ||
❑ In case of [[pericarditis]], avoid strenuous physical activity until symptoms resolve<br> | |||
❑ In case of [[pericarditis]], avoid | ❑ In case of [[myopericarditis]], avoid competitive sports for six months and/or until normalization of lab findings</div>}} | ||
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings | {{Family tree| | | | | | | | | | | | | | |!| |!| | | }} | ||
</div>}} | {{Family tree| | | | | | | | | | | | | | | F01 | | | F01= Assess response to treatment}} | ||
{{ | {{Family tree| | | | | | | | | | | | | |,|-|^|-|.| | }} | ||
{{ | {{Family tree| | | | | | | | | | | | | G01 | | G02 | G01= Response| G02= No response}} | ||
{{ | {{Family tree| | | | | | | | | | | | | |!| | | |!| | }} | ||
{{ | {{Family tree| | | | | | | | | | | | | H01 | | H02 | H01=<div style="text-align: left; padding:1em;">'''Follow up as outpatient:'''<br> | ||
{{ | ❑ Monitor for recurrences or constriction<br> | ||
{{ | ❑ Assess at 7 to 10 days for treatment response <br> | ||
❑ | ❑ Check blood tests and [[CRP]] at one month <BR> | ||
❑ Assess | ❑ Assess the patient thereafter only if symptoms recur | ||
❑ | </div>| H02=<div style="text-align: left; padding:1em;"> '''Admit to the hospital:''' | ||
❑ | ❑ Failure to respond to the initial therapy is an indication that the underlying cause may not be viral or idiopathic in nature. <br> | ||
❑ [[Pericarditis resident survival guide#Treatment#Etiology Specific Management|Order specific tests to identify the etiology and treat accordingly]]</div>}} | |||
❑ | {{Family tree/end}} | ||
❑ [[Pericarditis | |||
{{ | |||
===Treatment of Recurrent Pericarditis=== | ===Treatment of Recurrent Pericarditis=== | ||
Shown below is an algorithm summarizing the management of recurrent [[pericarditis]] in adults | Shown below is an algorithm summarizing the management of recurrent [[pericarditis]] in adults. Recurrent pericarditis can be classified into either '''incessant type''' (relapse of pericarditis following discontinuation of the anti-inflammatory medication) or '''intermittent type''' (relapse episode with symptom free interval without medical therapy).<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid23998693">{{cite journal| author=Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B et al.| title=American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 965-1012.e15 | pmid=23998693 | doi=10.1016/j.echo.2013.06.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998693 }} </ref><ref name="pmid15548780">{{cite journal |author=Lange RA, Hillis LD |title=Clinical practice. Acute pericarditis |journal=[[N. Engl. J. Med.]] |volume=351 |issue=21 |pages=2195–202 |year=2004 |month=November |pmid=15548780 |doi=10.1056/NEJMcp041997 |url=}}</ref> | ||
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❑ Characteristic [[Pericarditis echocardiography|acute pericarditis echocardiography changes]] <br> | ❑ Characteristic [[Pericarditis echocardiography|acute pericarditis echocardiography changes]] <br> | ||
❑ Massive [[pericardial effusion]], [[cardiac tamponade]], and pericardial constriction are rare <br> | ❑ Massive [[pericardial effusion]], [[cardiac tamponade]], and pericardial constriction are rare <br> | ||
'''Determine predisposing factors''' <br> | |||
❑ Insufficient dose or/and insufficient treatment duration in an autoimmune pericardial disease <br> | |||
❑ [[Corticosteroid]] treatment during the first episode<br> | |||
</div>}} | |||
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{{familytree | | | | | | | | | | D01 | | | | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;">'''Initiate medical therapy'''<br> | {{familytree | | | | | | | | | | D01 | | | | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;">'''Initiate medical therapy'''<br> | ||
'''[[NSAIDs]]'''<br> | '''[[NSAIDs]]'''<br> | ||
Avoid in [[Dressler's syndrome|post-MI pericarditis]] patients<br> | |||
❑ [[Ibuprofen]] | ❑ [[Ibuprofen]] (first line)<br> | ||
:❑ Orally 300-800 mg TID or QID x 1-2 weeks<br> | |||
:❑ Orally 300-800 mg | :❑ Taper gradually every 2-3 days <br>OR<br> | ||
:❑ | ❑ [[Indomethacin]] <br> | ||
❑ [[Indomethacin]] | :❑ Orally 50 mg TID x 1-2 weeks<br> | ||
:❑ Orally 50 mg | :❑ Taper gradually every 2-3 days for Rx period of 3-4 weeks<br> | ||
:❑ | |||
<br>'''OR'''<br> | |||
'''[[Aspirin]]'''<br> | '''[[Aspirin]]'''<br> | ||
❑ Drug of choice in | ❑ Drug of choice in [[Dressler's syndrome|post-MI pericarditis]] patients<br> | ||
❑ [[aspirin|High-dose aspirin]]: <br> | ❑ [[aspirin|High-dose aspirin]]: <br> | ||
:❑ Orally 800 mg QID | :❑ Orally 800 mg TID or QID x 7-10 days <BR> | ||
:❑ | :❑ Taper gradually by 800 mg/week for 3 additional weeks <br> | ||
❑ Stop [[anticoagulants]] if patient develops [[pericardial effusion]] <br> | ❑ Stop [[anticoagulants]] if patient develops [[pericardial effusion]] <br> | ||
<br>'''AND/OR'''<br> | |||
'''[[Colchicine]]:'''<br> | '''[[Colchicine]]:'''<br> | ||
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❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR> | ❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR> | ||
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | ❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR> | ||
'''Add gastroprotective agents:'''<br> | '''Add gastroprotective agents:'''<br> | ||
❑ [[Misoprostol]] (600 to 800 mg/day)<BR> | ❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR> | ||
❑ [[Omeprazole]] (20 mg/day) <br> | ❑ [[Omeprazole]] (20 mg/day) <br> | ||
---- | ---- | ||
'''Life style modification'''<br> | '''Life style modification'''<br> | ||
❑ | ❑ Exercise restriction until symptom resolution<br> | ||
<br> | <br> | ||
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{{familytree | | | | | | | | F01 | | F02 | | | | | | | | F01=<div style="float: left; text-align: left; padding:1em;">'''Taper [[steroids]]'''<br> | {{familytree | | | | | | | | F01 | | F02 | | | | | | | | F01=<div style="float: left; text-align: left; padding:1em;">'''Taper [[steroids]]'''<br> | ||
❑ Taper dose over a three-month period <br> | ❑ Taper dose over a three-month period <br> | ||
❑ If symptoms recur | ❑ If symptoms recur | ||
::❑ Start the last dose that suppressed the symptoms | ::❑ Start the last dose that suppressed the symptoms | ||
::❑ Maintain the dose for 2-3 weeks and then taper | ::❑ Maintain the dose for 2-3 weeks and then taper | ||
❑ Add [[colchicine]] or [[NSAIDs]] at the end of | ❑ Add [[colchicine]] or [[NSAIDs]] at the end of the steroid taper | ||
</div>| F02=<div style="float: left; text-align: left; padding:1em;"> | </div>| F02=<div style="float: left; text-align: left; padding:1em;"> | ||
❑ Add [[azathioprine]] (75–100 mg/day) or [[cyclophosphamide]]<br> | ❑ Add [[azathioprine]] (75–100 mg/day) or [[cyclophosphamide]]<br> | ||
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{{familytree | | | | | | | | | | D01 | | | | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;">'''Pericardiectomy'''<br> | {{familytree | | | | | | | | | | D01 | | | | | | | | | | D01=<div style="float: left; text-align: left; padding:1em;">'''Pericardiectomy'''<br> | ||
❑ Maintain the patient on [[steroid]] free regimen for several weeks before the procedure | ❑ Maintain the patient on a [[steroid]] free regimen for several weeks before the procedure | ||
❑ [[Pericarditis | ❑ [[Pericarditis resident survival guide#Etiology Specific Management|Order tests to identify the specific etiology and treat accordingly]]</div>}} | ||
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! Treatment | ! Treatment | ||
|- | |- | ||
| Viral pericarditis|| ❑ | | Viral pericarditis|| ❑ Test for viral etiologies in immunocompromised and [[HIV]] infected patients not responding to intial management<br> ❑ Diagnostic [[pericardiocentesis]]<br> ❑ Analysis of [[pericardial fluid]] (transudate or exudate)<br> ❑ [[PCR]] or in-situ hybridisation | ||
|| ❑ [[CMV]] pericarditis: Hyperimmunoglobulin OD 4 ml/kg on day 0, 4,and 8; 2 ml/kg on day 12 and 16 <br>❑ [[Coxsackie B]] pericarditis: [[Interferon]] alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3 x per week<br> ❑ [[Adenovirus]] and [[parvovirus B19]] perimyocarditis: [[Immunoglobulin]] 10 g IV at day 1 and 3 for 6-8 hours | || ❑ [[CMV]] pericarditis: Hyperimmunoglobulin OD 4 ml/kg on day 0, 4,and 8; 2 ml/kg on day 12 and 16 <br>❑ [[Coxsackie B]] pericarditis: [[Interferon]] alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3 x per week<br> ❑ [[Adenovirus]] and [[parvovirus B19]] perimyocarditis: [[Immunoglobulin]] 10 g IV at day 1 and 3 for 6-8 hours | ||
|- | |- | ||
| Purulent pericarditis|| ❑ Diagnostic [[pericardiocentesis]] in cases of high clinical suspicion <br> ❑ [[Gram stain]], acid fast stain, fungal stain, and cultures of the pericardial fluid <br> ❑ [[Protein]], [[glucose]] and cell count of the pericardial fluid <br> ❑ [[Gram stain]], acid fast stain, fungal stain, and cultures of other body fluids ||❑ Therapeutic [[pericardiocentesis]] or [[pericardial window]]<br> ❑ [[Pericardiectomy]] may be used in treatment of recurrent [[pericardial effusion]] and in patients with dense adhesions, loculated and thick purulent effusion<br> ❑ [[Pericarditis treatment#Management of Complicated Pericarditis|Antimicrobial therapy]] in case of bacterial etiology<br> ❑ | | Purulent pericarditis|| ❑ Diagnostic [[pericardiocentesis]] in cases of high clinical suspicion <br> ❑ [[Gram stain]], acid fast stain, fungal stain, and cultures of the pericardial fluid <br> ❑ [[Protein]], [[glucose]] and cell count of the pericardial fluid <br> ❑ [[Gram stain]], acid fast stain, fungal stain, and cultures of other body fluids ||❑ Therapeutic [[pericardiocentesis]] or [[pericardial window]]<br> ❑ [[Pericardiectomy]] may be used in treatment of recurrent [[pericardial effusion]] and in patients with dense adhesions, loculated and thick purulent effusion<br> ❑ [[Pericarditis treatment#Management of Complicated Pericarditis|Antimicrobial therapy]] in case of bacterial etiology<br> ❑ Antistaphylococcal antibiotic plus [[aminoglycoside]], followed by tailored antibiotic therapy according to pericardial fluid and blood cultures<br> ❑ Empiric regimen can be started for the following <br> ❑ [[Immunosuppression]]<br> ❑ Concurrent infection at another body site<br> ❑ Presence of intravascular lines or prosthetic devices <br> ❑ Recent antimicrobial therapy <br> ❑ [[Pericarditis treatment#Management of Complicated Pericarditis|Antifungal therapy]] in case of fungal etiology | ||
|- | |- | ||
| [[Tuberculous pericarditis]]|| ❑ Diagnostic [[pericardiocentesis]] in all suspected tuberculous pericarditis patients <br> ❑ [[PCR]] of pericardial fluid<br> ❑ High [[adenosine deaminase]] activity and interferon gamma concentration in [[pericardial effusion]] <br> ❑ Pericardial biopsy (rapid diagnosis) <br> ❑ [[Tuberculin skin test]] (not helpful) <br> ❑ [[CT scan]] and/or [[MRI]] of the chest <br> ❑ Culture of sputum, gastric aspirate, and/or urine <br>❑ Enzyme-linked immunospot (ELISPOT)<br> ❑ Serum titres of antimyolemmal and antimyosin antibodies||❑[[Tuberculous pericarditis medical therapy|Anti-tuberculosis chemotherapy]]<br> ❑ Emperic therapy in TB endemic areas and in cases with high clinical suspicion<br> ❑ [[Pericardiectomy]] is warranted in the setting of persistent [[constrictive pericarditis]] or when no general improvement after 4-8 weeks following antituberculosis chemotherapy<br> ❑ [[Tuberculous pericarditis medical therapy#Role of Corticosteroids in Tuberculous pericarditis|Prednisone]] can be used | | [[Tuberculous pericarditis]]|| ❑ Diagnostic [[pericardiocentesis]] in all suspected tuberculous pericarditis patients <br> ❑ [[PCR]] of pericardial fluid<br> ❑ High [[adenosine deaminase]] activity and interferon gamma concentration in [[pericardial effusion]] <br> ❑ Pericardial biopsy (rapid diagnosis) <br> ❑ [[Tuberculin skin test]] (not helpful) <br> ❑ [[CT scan]] and/or [[MRI]] of the chest <br> ❑ Culture of sputum, gastric aspirate, and/or urine <br>❑ Enzyme-linked immunospot (ELISPOT)<br> ❑ Serum titres of antimyolemmal and antimyosin antibodies||❑[[Tuberculous pericarditis medical therapy|Anti-tuberculosis chemotherapy]]<br> ❑ Emperic therapy in TB endemic areas and in cases with high clinical suspicion<br> ❑ [[Pericardiectomy]] is warranted in the setting of persistent [[constrictive pericarditis]] or when no general improvement after 4-8 weeks following antituberculosis chemotherapy<br> ❑ [[Tuberculous pericarditis medical therapy#Role of Corticosteroids in Tuberculous pericarditis|Prednisone]] can be used | ||
|- | |- | ||
| Neoplastic [[pericarditis]] ||❑ [[CT scan]] and/or [[MRI]] of the chest <br> ❑ Diagnostic [[pericardiocentesis]] when other tests couldnt identify [[malignancy]]<br>❑ Cytology and tumour markers <br> ❑ Pericardial biopsy || ❑ Systemic antineoplastic treatment <br> ❑ Assess the life expectancy of the patients before proceeding with the treatment<br> ❑ Better prognosis patients should be treated more aggressively <br> ❑ Advanced [[malignancy]] should be treated palliatively with [[pericardiocentesis]] <br> ❑ Recurrence of pericardial effusion is prevented using any of the following techniques <br> ❑ Prolonged pericardiocentesis <br> ❑ Pericardial sclerosis <br> ❑ Pericardiotomy <br> ❑ Intrapericardial chemotherapy | | Neoplastic [[pericarditis]] ||❑ [[CT scan]] and/or [[MRI]] of the chest <br> ❑ Diagnostic [[pericardiocentesis]] when other tests couldnt identify [[malignancy]]<br>❑ Cytology and tumour markers <br> ❑ Pericardial biopsy || ❑ Systemic antineoplastic treatment <br> ❑ Assess the life expectancy of the patients before proceeding with the treatment<br> ❑ Better prognosis patients should be treated more aggressively <br> ❑ Advanced [[malignancy]] should be treated palliatively with [[pericardiocentesis]] <br> ❑ Recurrence of pericardial effusion is prevented using any of the following techniques <br> ❑ Prolonged pericardiocentesis <br> ❑ Pericardial sclerosis <br> ❑ Pericardiotomy <br> ❑ Intrapericardial chemotherapy | ||
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==Do's== | ==Do's== | ||
*Always suspect [[acute pericarditis]] in the presence of characteristic pleuritic chest pain and [[pericardial friction rub]]. Also suspect pericarditis in a patient with persistent [[fever]] and pericardial effusion or new unexplained [[cardiomegaly]]. | * Always suspect [[acute pericarditis]] in the presence of characteristic pleuritic chest pain and [[pericardial friction rub]]. Also suspect pericarditis in a patient with persistent [[fever]] and pericardial effusion or new unexplained [[cardiomegaly]]. | ||
* | * Always first suspect acute [[cardiac tamponade]] in any patient presenting with [[Beck's triad]]: [[hypotension]], muffled heart sounds and distended neck veins (or elevated [[jugular venous pressure]]).<ref name="Sternbach-">{{Cite journal | last1 = Sternbach | first1 = G. | last2 = Beck | first2 = C. | title = Claude Beck: cardiac compression triads. | journal = J Emerg Med | volume = 6 | issue = 5 | pages = 417-9 | month = | year = | doi = | PMID = 3066820 }}</ref> | ||
* [[ | * Initiate systemic [[corticosteroid]] therapy to treat [[pericarditis]] due to autoreactive or [[connective tissue diseases]] and [[Uremic pericarditis|uremia]]. Use intrapericardial application to avoid systemic side effects. Use moderate initial dosing of steroids followed by a slow taper and introduce [[ibuprofen]] or [[colchicine]] early during tapering of steroids. | ||
* Order an analysis of [[pericardial effusion]] in required cases for different etiologies according to the clinical presentation. | |||
* Order an analysis of [[pericardial effusion]] for different etiologies according to the clinical presentation. | |||
* Assess for the presence of [[coagulopathy]] or the intake of [[antithrombotic]] medications before choosing the modality of drainage of the pericardial fluid. | * Assess for the presence of [[coagulopathy]] or the intake of [[antithrombotic]] medications before choosing the modality of drainage of the pericardial fluid. | ||
* Choose [[pericardiocentesis]] rather than surgical drainage as a therapeutic option unless the patient has an indication for surgical drainage. | * Choose [[pericardiocentesis]] rather than surgical drainage as a therapeutic option unless the patient has an indication for surgical drainage. | ||
* When surgical drainage is indicated but the patient has severe [[hypotension]] prohibiting the induction of [[anesthesia]], perform [[pericardiocentesis]] in the operating room before surgery.<ref name="pmid23376916">{{cite journal| author=Schiavone WA| title=Cardiac tamponade: 12 pearls in diagnosis and management. | journal=Cleve Clin J Med | year= 2013 | volume= 80 | issue= 2 | pages= 109-16 | pmid=23376916 | doi=10.3949/ccjm.80a.12052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23376916 }} </ref> | * When surgical drainage is indicated but the patient has severe [[hypotension]] prohibiting the induction of [[anesthesia]], perform [[pericardiocentesis]] in the operating room before surgery.<ref name="pmid23376916">{{cite journal| author=Schiavone WA| title=Cardiac tamponade: 12 pearls in diagnosis and management. | journal=Cleve Clin J Med | year= 2013 | volume= 80 | issue= 2 | pages= 109-16 | pmid=23376916 | doi=10.3949/ccjm.80a.12052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23376916 }} </ref> | ||
* Monitor closely patients who underwent [[pericardiocentesis]] for postdrainage decompensation. | * Monitor closely patients who underwent [[pericardiocentesis]] for postdrainage decompensation. | ||
* [[Heparin]] is recommended under strict observation for patients who need anticoagulant therapy. | |||
==Don'ts== | ==Don'ts== | ||
* Avoid [[pericardiocentesis]] in cases where the diagnosis can be made based on systemic features or when the effusions are very small or resolving with anti-inflammatory treatment. | * Avoid [[pericardiocentesis]] in cases where the diagnosis can be made based on systemic features or when the effusions are very small or resolving with anti-inflammatory treatment. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Medicine]] | [[Category:Medicine]] | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
Latest revision as of 15:02, 19 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]
Pericarditis Resident Survival Guide Microchapters |
---|
Overview |
Causes |
FIRE |
Complete Diagnostic Approach |
Treatment |
Do's |
Don'ts |
Overview
Pericarditis is the inflammation of the fibroelastic sac surrounding the heart (pericardium). Pericarditis is classified either as either acute (<6 weeks), subacute (6 weeks to 6 months) or chronic (>6 months) in duration and it can be further classified as either dry, fibrinous or effusive. Myopericarditis, or perimyocarditis refers to acute pericarditis associated with myocardial inflammation that leads to global or regional myocardial dysfunction and elevation in the concentration of troponins, creatine kinase MB, myoglobin and tumour necrosis factor.[1] Pericarditis should be suspected in the presence of pleuritic chest pain that is positional along with a pericardial friction rub. NSAIDs are the mainstay of the treatment of acute pericarditis; ibuprofen is administered most often.[2]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Autoimmune: Rheumatoid arthritis, Sjögren’s syndrome, SLE, systemic sclerosis, systemic vasculitis
- Bacterial: Coxiella burnetii, pneumococcus, staphylococcus, streptococcus, tuberculosis[3]
- Cardiovascular: Dressler's syndrome, postpericardiotomy syndrome, post-traumatic pericarditis[4]
- Idiopathic
- Metabolic: Myxedema, uremia
- Neoplastic: Breast cancer, leukemia, lung cancer, lymphoma
- Viral: Adenovirus, CMV, coxsackie, EBV, echovirus, HBV, HIV, human herpes virus 6, influenza, mumps, parvovirus B19, rubella, varicella[3]
Click here for the complete list of causes.
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2]
Boxes in red color signify that an urgent management is needed.
Abbreviations: ECG: electrocardiogram
Identify cardinal findings that increase the pretest probability of acute pericarditis ❑ Characteristic chest pain
❑ Suggestive ECG changes
| |||||||||||||||||||||||||||||||||
Does the patient have the following clinical findings suggestive of cardiac tamponade? ❑ Sinus tachycardia | |||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||
❑ Order (urgent): ❑ Immediately transfer the patient to ICU | |||||||||||||||||||||||||||||||||
Indications for pericardiocentesis:
❑ Findings suggestive of unstable cardiac tamponade:
❑ Effusions > 20 mm in echocardiography in diastole | |||||||||||||||||||||||||||||||||
Does the patient have any absolute contraindication for pericardiocentesis:
❑ Aortic dissection | |||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||
Perform pericardiocentesis:
❑ Subxiphoid approach (most preferred)
❑ Discontinue anticoagulation drugs and initiate FFP if there is high INR | Perform surgical drainage:
❑ Also more appropriate for:
| ||||||||||||||||||||||||||||||||
Complete Diagnostic Approach to Acute Pericarditis
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2][6][4]
Abbreviations: TDS: three times a day; QID: four times a day; wk: week
Characterize the symptoms:
Symptoms associated with pericardial effusion:
❑ With a hemodynamically significant pericardial effusion
Other etiology associated symptoms: | |||||||||||||||||||||||||||||||
Obtain a detailed history: ❑ Infections
❑ Systemic illness ❑ Others | |||||||||||||||||||||||||||||||
Examine the patient: Vital signs
Cardiovascular system Auscultation
❑ Murmur (in concomitant heart disease)
Palpation
Percussion Respiratory system ❑ Wheeze or rales Abdomen ❑ Pulsatile hepatomegaly (in constrictive pericarditis) | |||||||||||||||||||||||||||||||
Order tests (Urgent): Order laboratory tests (urgent): Order electrocardiogram (urgent): ❑ Typical findings in pericarditis
❑ Electrical alternans (in cardiac tamponade) Order imaging (urgent):
| |||||||||||||||||||||||||||||||
Does the patient have at least two of the following criteria for the diagnosis of acute pericarditis? ❑ Characteristic chest pain
❑ Suggestive ECG changes
❑ Suggestive echocardiography changes
| |||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||
Does the patient have any sign of myocarditis? ❑ Elevated cardiac enzymes, or ❑ Global or regional myocardial dysfunction on echocardiography | Does the patient have any signs suspicious of acute pericarditis? ❑ Ongoing fever | ||||||||||||||||||||||||||||||
No | Yes | No | Yes | ||||||||||||||||||||||||||||
Acute pericarditis | Myopericarditis | Consider alternative diagnosis and treat accordingly | Consider cardiac MRI (CMR)[8] | ||||||||||||||||||||||||||||
Treat as acute pericarditis or myopericarditis if there is delayed enhancement on CMR | |||||||||||||||||||||||||||||||
Treatment
Treatment of Acute Pericarditis
Shown below is an algorithm summarizing the management of acute pericarditis in adults.[2][6][4]
Abbreviations: CRP: C-reactive protein; MI: Myocardial infarction
Does the patient have any of the following high risk features? ❑ Fever >38°C | |||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||
Inpatient treatment | Outpatient treatment | ||||||||||||||||||||||||||||||||||||||
Unstable patient
| Stable post MI patient | Stable patient without prior MI | Post MI | No previous MI | |||||||||||||||||||||||||||||||||||
Treat cardiac tamponade ❑ Click here for cardiac tamponade resident survival guide
Initiate medical therapy
Administer aspirin
❑ Stop anticoagulants if patient develops pericardial effusion
Administer colchicine
Order tests to identify the specific etiology Educate about life style modification | Initiate medical therapy Administer High-dose aspirin
Administer Colchicine Administer gastroprotective agents
Avoid NSAIDs (ibuprofen) Avoid steroids ❑ Stop anticoagulants if the patient develops pericardial effusion Order tests to identify the specific etiology Educate about life style modification | Initiate medical therapy Administer NSAIDs (First line)
Administer Colchicine
Order tests to identify the specific etiology Order pericardiocentesis in case of Educate about life style modification | Initiate medical therapy Administer High-dose aspirin
Administer Colchicine Administer gastroprotective agents
Avoid NSAIDs (ibuprofen) Avoid steroids ❑ Stop anticoagulants if the patient develops pericardial effusion Order tests to identify the specific etiology Educate about life style modification | Initiate medical therapy Administer NSAID's
Colchicine Administer gastroprotective agents
Avoid steroids Educate about life style modification | |||||||||||||||||||||||||||||||||||
Assess response to treatment | |||||||||||||||||||||||||||||||||||||||
Response | No response | ||||||||||||||||||||||||||||||||||||||
Follow up as outpatient: ❑ Monitor for recurrences or constriction | Admit to the hospital:
❑ Failure to respond to the initial therapy is an indication that the underlying cause may not be viral or idiopathic in nature. | ||||||||||||||||||||||||||||||||||||||
Treatment of Recurrent Pericarditis
Shown below is an algorithm summarizing the management of recurrent pericarditis in adults. Recurrent pericarditis can be classified into either incessant type (relapse of pericarditis following discontinuation of the anti-inflammatory medication) or intermittent type (relapse episode with symptom free interval without medical therapy).[2][6][4]
Recurrent pericarditis | |||||||||||||||||||||||||||||||||||||||||||||||||
Characterize the clinical, EKG and imaging findings ❑ Characteristic acute pericarditis symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||
Initiate medical therapy NSAIDs
Aspirin
❑ Stop anticoagulants if patient develops pericardial effusion
Colchicine: Add gastroprotective agents: Life style modification ❑ Exercise restriction until symptom resolution | |||||||||||||||||||||||||||||||||||||||||||||||||
Multiple relapses | |||||||||||||||||||||||||||||||||||||||||||||||||
Positive response | No response | ||||||||||||||||||||||||||||||||||||||||||||||||
Taper steroids ❑ Taper dose over a three-month period
❑ Add colchicine or NSAIDs at the end of the steroid taper | ❑ Add azathioprine (75–100 mg/day) or cyclophosphamide | ||||||||||||||||||||||||||||||||||||||||||||||||
Treatment failure | |||||||||||||||||||||||||||||||||||||||||||||||||
Pericardiectomy ❑ Maintain the patient on a steroid free regimen for several weeks before the procedure ❑ Order tests to identify the specific etiology and treat accordingly | |||||||||||||||||||||||||||||||||||||||||||||||||
Etiology Specific Management
Clinical subgroups | Specific investigations | Treatment |
---|---|---|
Viral pericarditis | ❑ Test for viral etiologies in immunocompromised and HIV infected patients not responding to intial management ❑ Diagnostic pericardiocentesis ❑ Analysis of pericardial fluid (transudate or exudate) ❑ PCR or in-situ hybridisation |
❑ CMV pericarditis: Hyperimmunoglobulin OD 4 ml/kg on day 0, 4,and 8; 2 ml/kg on day 12 and 16 ❑ Coxsackie B pericarditis: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3 x per week ❑ Adenovirus and parvovirus B19 perimyocarditis: Immunoglobulin 10 g IV at day 1 and 3 for 6-8 hours |
Purulent pericarditis | ❑ Diagnostic pericardiocentesis in cases of high clinical suspicion ❑ Gram stain, acid fast stain, fungal stain, and cultures of the pericardial fluid ❑ Protein, glucose and cell count of the pericardial fluid ❑ Gram stain, acid fast stain, fungal stain, and cultures of other body fluids |
❑ Therapeutic pericardiocentesis or pericardial window ❑ Pericardiectomy may be used in treatment of recurrent pericardial effusion and in patients with dense adhesions, loculated and thick purulent effusion ❑ Antimicrobial therapy in case of bacterial etiology ❑ Antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures ❑ Empiric regimen can be started for the following ❑ Immunosuppression ❑ Concurrent infection at another body site ❑ Presence of intravascular lines or prosthetic devices ❑ Recent antimicrobial therapy ❑ Antifungal therapy in case of fungal etiology |
Tuberculous pericarditis | ❑ Diagnostic pericardiocentesis in all suspected tuberculous pericarditis patients ❑ PCR of pericardial fluid ❑ High adenosine deaminase activity and interferon gamma concentration in pericardial effusion ❑ Pericardial biopsy (rapid diagnosis) ❑ Tuberculin skin test (not helpful) ❑ CT scan and/or MRI of the chest ❑ Culture of sputum, gastric aspirate, and/or urine ❑ Enzyme-linked immunospot (ELISPOT) ❑ Serum titres of antimyolemmal and antimyosin antibodies |
❑Anti-tuberculosis chemotherapy ❑ Emperic therapy in TB endemic areas and in cases with high clinical suspicion ❑ Pericardiectomy is warranted in the setting of persistent constrictive pericarditis or when no general improvement after 4-8 weeks following antituberculosis chemotherapy ❑ Prednisone can be used |
Neoplastic pericarditis | ❑ CT scan and/or MRI of the chest ❑ Diagnostic pericardiocentesis when other tests couldnt identify malignancy ❑ Cytology and tumour markers ❑ Pericardial biopsy |
❑ Systemic antineoplastic treatment ❑ Assess the life expectancy of the patients before proceeding with the treatment ❑ Better prognosis patients should be treated more aggressively ❑ Advanced malignancy should be treated palliatively with pericardiocentesis ❑ Recurrence of pericardial effusion is prevented using any of the following techniques ❑ Prolonged pericardiocentesis ❑ Pericardial sclerosis ❑ Pericardiotomy ❑ Intrapericardial chemotherapy |
Pericarditis in renal failure | ❑ Renal function test ❑ Diagnostic pericardiocentesis ❑ Pericardial biopsy |
❑ Uremic pericarditis ❑ Hemodialysis or peritoneal dialysis ❑ Heparin-free haemodialysis should be used ❑ Dialysis-associated pericarditis ❑ Pericardiocentesis for large effusion ❑ Pericardiotomy in non resolving effusion |
Pericarditis in systemic autoimmune disease | ❑ Diagnostic pericardiocentesis ❑ Elevated lymphocytes and mononuclear cells > 5000/mm3 ❑ Antisarcolemmal antibodies ❑ Exclusion of viral and bacterial etiologies |
❑ NSAIDs or aspirin or colchicine ❑ Systemic corticosteroid can be used ❑ Intrapericardial steroids has less side effects and is highly effective |
Do's
- Always suspect acute pericarditis in the presence of characteristic pleuritic chest pain and pericardial friction rub. Also suspect pericarditis in a patient with persistent fever and pericardial effusion or new unexplained cardiomegaly.
- Always first suspect acute cardiac tamponade in any patient presenting with Beck's triad: hypotension, muffled heart sounds and distended neck veins (or elevated jugular venous pressure).[10]
- Initiate systemic corticosteroid therapy to treat pericarditis due to autoreactive or connective tissue diseases and uremia. Use intrapericardial application to avoid systemic side effects. Use moderate initial dosing of steroids followed by a slow taper and introduce ibuprofen or colchicine early during tapering of steroids.
- Order an analysis of pericardial effusion in required cases for different etiologies according to the clinical presentation.
- Assess for the presence of coagulopathy or the intake of antithrombotic medications before choosing the modality of drainage of the pericardial fluid.
- Choose pericardiocentesis rather than surgical drainage as a therapeutic option unless the patient has an indication for surgical drainage.
- When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery.[5]
- Monitor closely patients who underwent pericardiocentesis for postdrainage decompensation.
- Heparin is recommended under strict observation for patients who need anticoagulant therapy.
Don'ts
- Avoid pericardiocentesis in cases where the diagnosis can be made based on systemic features or when the effusions are very small or resolving with anti-inflammatory treatment.
References
- ↑ Imazio M (2012). "Contemporary management of pericardial diseases". Curr Opin Cardiol. 27 (3): 308–17. doi:10.1097/HCO.0b013e3283524fbe. PMID 22450720.
- ↑ 2.0 2.1 2.2 2.3 2.4 Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y; et al. (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology". Eur Heart J. 25 (7): 587–610. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
- ↑ 3.0 3.1 Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y (2010). "Controversial issues in the management of pericardial diseases". Circulation. 121 (7): 916–28. doi:10.1161/CIRCULATIONAHA.108.844753. PMID 20177006.
- ↑ 4.0 4.1 4.2 4.3 Lange RA, Hillis LD (2004). "Clinical practice. Acute pericarditis". N Engl J Med. 351 (21): 2195–202. doi:10.1056/NEJMcp041997. PMID 15548780.
- ↑ 5.0 5.1 Schiavone WA (2013). "Cardiac tamponade: 12 pearls in diagnosis and management". Cleve Clin J Med. 80 (2): 109–16. doi:10.3949/ccjm.80a.12052. PMID 23376916.
- ↑ 6.0 6.1 6.2 Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B; et al. (2013). "American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography". J Am Soc Echocardiogr. 26 (9): 965–1012.e15. doi:10.1016/j.echo.2013.06.023. PMID 23998693.
- ↑ "WHO launches World health report 2013". Euro Surveill. 18 (33): 20559. 2013. PMID 23968879.
- ↑ Khandaker MH, Espinosa RE, Nishimura RA; et al. (2010). "Pericardial disease: diagnosis and management". Mayo Clinic Proceedings. Mayo Clinic. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488. Unknown parameter
|month=
ignored (help) - ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Goldfinger S (2014). "A randomized trial of colchicine for acute pericarditis". N Engl J Med. 370 (8): 780. doi:10.1056/NEJMc1315351#SA1. PMID 24552334.
- ↑ Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.