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Pericarditis

Nov 08, 20245 min read

Acute Pericarditis

# Acute pericarditis
- Work-up: CBC, ESR, CRP, CK, troponin, 12-lead ECG, CXR
- Echo
- Empiric therapy
	- Aspirin 750-1,000 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 250-500 mg every 1-2 weeks
	- Ibuprofen 600 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 200-400 mg every 1-2 weeks.
	- Colchicine 0.6 mg BID (if weight > 70 kg) or 0.5 mg daily (if weight < 70 kg). 
	- PPI for gastroprotection (if prescribed ASA or NSAIDs)
- Activity limitations
	- If not involved in athletic sports, recommend restrict physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP
	- If athlete, recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG and echocardiogram) have normalized
	- Duration: Expert consensus recommends activity restriction for a minimum of 3 months for athletes, whereas a shorter period (until remission) may be suitable for non-athletes.
- Dispo: close follow-up in 1 week to assess therapeutic response
  • Acute pericarditis is an inflammatory pericardial syndrome with or without pericardial effusion.
  • Poor prognostic markers – if present, may warrant hospital admission
    • Fever
    • Subacute course, i.e. Sx over several days w/o a clear-cut onset
    • Large pericardial effusion, i.e. diastolic echo-free space >2 cm
    • Cardiac tamponade
    • Failure to respond w/in 7 days to NSAIDs

Diagnosis of Acute Pericarditis

  • Clinical diagnosis can be made with ≥2 of the following criteria:
    • chest pain (>85–90% of cases)—typically sharp and pleuritic, improved by sitting up and leaning forward
    • pericardial friction rub (≤33% of cases)—a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope 🩺 over the left sternal border
    • ECG changes (up to 60% of cases)—with new widespread ST elevation or PR depression in the acute phase
      • NOTE: ECG changes imply inflammation of the epicardium, since the parietal pericardium itself is electrically inert
    • pericardial effusion (up to 60% of cases, generally mild)
  • CRP, ESR, WBC elevation is common and may be helpful to monitor disease activity and therapeutic efficacy
  • Increased markers of myocardial injury (e.g. CK, troponin) may suggest concomitant myocarditis

Management of Acute Pericarditis

Table source: 1

DrugUsual DosingTx DurationTapering
Aspirin750-1,000 mg q8h1-2 wks↓ dose by 250-500 mg every 1-2 wks
Ibuprofen600 mg q8h1-2 wks↓ dose by 200-400 mg every 1-2 wks
Colchicine0.5 mg daily (< 70 kg) or 0.5 mg BID (≥ 70 kg)3 monthsNot mandatory, alternatively 0.5 mg every other day (< 70 kg) or 0.5 mg once (270 kg) in the last weeks
  • Empiric therapy
    • Aspirin 750-1,000 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 250-500 mg every 1-2 weeks
    • Ibuprofen 600 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 200-400 mg every 1-2 weeks.
    • Colchicine 0.6 mg BID (if weight > 70 kg) or 0.5 mg daily (if weight < 70 kg). Often prescribed as adjunct to Aspirin/NSAID. Tapering is not mandatory.
      • Contraindicated if severe renal impairment, pregnant/lactating women
    • 📝 Steroids only used if contraindications and failure to ASA/NSAIDs. If used, low to moderate doses (i.e. prednisone 0.2—0.5 mg/kg/day or equivalent) should be recommended instead of high doses (i.e. prednisone 1.0 mg/kg/day or equivalent). initial dose should be maintained until resolution of symptoms and normalization of CRP, then tapering should be considered.
  • PPI for gastroprotection (if prescribed ASA or NSAIDs)
  • Activity limitations
    • If not involved in athletic sports, recommend restrict physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP
    • If athlete 🏃, recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG and echocardiogram) have normalized
    • Duration: Expert consensus recommends activity restriction for a minimum of 3 months for athletes, whereas a shorter period (until remission) may be suitable for non-athletes.
  • Dispo: close follow-up in 1 week to assess therapeutic response

Incessant Pericarditis

Recurrent Pericarditis

  • Try to target underlying etiology (if identifiable cause present)
  • Aspirin or NSAIDs remain the mainstay of therapy + Colchicine as adjunct
  • If incomplete response to ASA/NSAID + colchicine combo, then can consider steroids as an add-on to low-/moderate-dose ASA/NSAID + colchicine, i.e. ‘triple therapy’
    • See ESC 2015 guidelines for recommendations on tapering steroid therapy

  • Drugs such as IVIG, anakinra and azathioprine may be considered in cases of proven infection-negative, corticosteroid-dependent, recurrent pericarditis not responsive to colchicine after careful assessment of the costs, risks and eventually consultation by multidisciplinary experts, including immunologists and/or rheumatologists, in the absence of a specific expertise. It is also mandatory to educate the patient and his/her caregivers about the clinical risks related to immunomodulatory/immunosuppressive drugs and the safety measures to adopt during the treatment.
  • As a last resort, pericardiectomy may be considered, but only after a thorough trial of unsuccessful medical therapy, and with referral of the patient to a centre with specific expertise in this surgery.

Chronic Pericarditis

Footnotes

  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart Journal. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318 ↩

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