Pericarditis treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
The management of pericarditis depends upon whether the patient has an uncomplicated or a complicated disease course. Uncomplicated pericarditis is generally treated with non-steroidal anti-inflammatory drugs such as ibuprofen in case of viral or idiopathic pericarditis and aspirin in case of post-MI pericarditis. Pericarditis complicated with effusion or cardiac tamponade is generally treated with urgent pericardiocentesis in case of cardiac tamponade, antibiotics in case of purulent pericardial effusion, and steroids or colchicine in patients with recurrent or refractory disease.
Management of Uncomplicated Pericarditis
Patients with uncomplicated acute pericarditis can generally be treated and followed up in an outpatient clinic. The treatment of viral or idiopathic pericarditis is with non-steroidal anti-inflammatory drugs. Patients should be observed for side effects since NSAIDs are known to affect the GI mucosa. If the underlying cause of pericarditis is something other than a viral cause, the specific etiology should be treated.
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are the mainstay of therapy for uncomplicated pericarditis (viral or idiopathic pericarditis). The goal of therapy is to reduce pain and inflammation. While symptoms are improved by NSAIDs, the duration of the episode may not be reduced. The preferred NSAID is ibuprofen which has a large range of doses that can be titrated to the patient's tolerance.[1] Depending on the severity of symptoms, the dosing is between 300-800 mg every 6-8 hours for days or weeks as needed. In order to minimize a recurrence of symptoms, a slow tapering of the NSAID dose may be required. As with all NSAID use, GI prophylaxis should be strongly considered.
Aspirin Therapy
An alternative therapy is aspirin 800 mg every 6-8 hours.[2]
Post-MI Pericarditis
In pericarditis following acute myocardial infarction, NSAIDs other than aspirin should be avoided since they can impair scar formation.
Failure to Respond to a Week of Traditional Therapy
Failure to respond to NSAIDs within one week (as indicated by persistence of fever, a worsening of symptoms such as chest pain, the development of a new pericardial effusion), likely indicates that the underlying cause may not be viral or idiopathic in nature. These patients may require re-evaluation, observation, and more aggressive therapy as described in the next section.
Colchicine
In the European guidelines, colchicine carries a class IIa recommendation for the treatment of an initial episode of pericarditis along with an NSAID. The dose is 0.6 mg bid for 3 months. The rate of recurrence is lowered with colchicine therapy from 32.3% to 10.7%.
Steroids
Steroids are not used to treat an initial episode of pericarditis. They provide rapid relief in pain, but are associated with a high rate of recurrence.
Identification of High Risk or Complicated Pericarditis
Patients at high risk of developing complications of pericarditis may required admission to an inpatient service for careful observation for hemodynamic compromise. High risk patients include those with:[2]
- Acute onset
- High fever (> 100.4°F) and leukocytosis
- Development of cardiac tamponade
- Large pericardial effusion (echo-free space > 20 mm) resistant to NSAID treatment
- Immunocompromised status
- History of oral anticoagulation therapy
- Pericarditis secondary to acute trauma
- Failure to respond to seven days of NSAID treatment
Management of Complicated Pericarditis
- Pericardiocentesis may be required to relieve a large effusion or to treat cardiac tamponade.
- Antibiotics may be required to manage an underlying infection or a purulent pericarditis.
- Steroids may be required in recurrent refractory cases or in patients with autoimmune disease.
- Colchicine may be required in patients with recurrent or refractory disease (see below).
- Surgery may be required in the presence of recurrent effusion or constrictive pericarditis.
Management of Cardiac Tamponade and Large Pericardial Effusion
Pericardiocentesis is an invasive procedure in which the pericardial fluid is drained through a needle. A pericardial window is a surgical procedure to drain fluid form the pericardium. Indications for a pericardiocentesis or a pericardial window include the following:[1]
- Cardiac tamponade
- Large, persistent, symptomatic pericardial effusion
- For diagnostic purposes, if there is suspected purulent, tuberculosis, or neoplastic pericarditis.
Management of Recurrent Pericarditis
Class 1
Colchicine can be used alone or in conjunction with NSAIDs in prevention of recurrent pericarditis and treatment of recurrent pericarditis. Treatment involves a NSAID plus colchicine 2 mg on first day followed by 1 mg daily [3] for three months. [3][4][5]
Class 2a
Corticosteroids are usually used in those cases that are clearly refractory to NSAIDs and colchicine and a specific cause has not been found. Systemic corticosteroids are usually reserved for those with autoimmune disease. Steroids are sometimes used in post-operative pericarditis as well.
Class 2a
Pericardiectomy can be performed if the patient is refractory to medical therapy as a last resort. Most patients will respond to 2 to 3 months of aggressive medical therapy.
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Pericardial Diseases (DO NOT EDIT) [6]
| Class I |
| "1. Ventricular arrhythmias that develop in patients with pericardial disease should be treated in the same manner that such arrhythmias are treated in patients with other diseases including ICD and pacemaker implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
References
- ↑ 1.0 1.1 Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH (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): 587–10. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
- ↑ 2.0 2.1 Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J Am Coll Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
- ↑ Adler Y, Zandman-Goddard G, Ravid M, Avidan B, Zemer D, Ehrenfeld M, Shemesh J, Tomer Y, Shoenfeld Y (1994). "Usefulness of colchicine in preventing recurrences of pericarditis". Am J of Cardiol. 73 (12): 916–7. doi:10.1016/0002-9149(94)90828-1. PMID 8184826.
- ↑ Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial". Circulation. 112 (13): 2012–6. doi:10.1161/CIRCULATIONAHA.105.542738. PMID 16186437.
- ↑ Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial". Arch Intern Med. 165 (17): 1987–91. doi:10.1001/archinte.165.17.1987. PMID 16186468.
- ↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.