Pericarditis treatment On the Web
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The management of pericarditis depends on whether the patient has an uncomplicated vs. complicated disease course. Uncomplicated pericarditis is generally treated with non-steroidal anti-inflammatory drugs, such as Ibuprofen in cases of either viral or idiopathic pericarditis, and Aspirin in cases of post-MI pericarditis. Pericarditis complicated with either effusion or cardiac tamponade is generally treated with urgent pericardiocentesis in the case of cardiac tamponade, antibiotics in the case of purulent pericardial effusion, and either steroids or colchicine among 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. 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 recommended. Gastroprotection with misoprostol (600 to 800 g/day) or omeprazole (20 mg/day) is highly recommended. The gastroprotection recommendation is based on several studies have evaluated factors that place patients at increased risk of gastroduodenal toxicity from NSAIDs.
- The American College of Gastroenterology identified the five most important risk factors for gastroduodenal toxicity:
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.
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. It should be noted that a long term treatment of colchicine for several weeks or months should be considered, even after disappearance of effusion. 
For example, in a multicenter, double-blind trial, the use of colchicine at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg in acute pericarditis, when added to conventional antiinflammatory therapy with aspirin or ibuprofen, significantly reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), the hospitalization rate (5.0% vs. 14.2%, P = 0.02), and the remission rate at 1 week (85.0% vs. 58.3%, P<0.001), as compared with placebo.
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:
- 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
- Antibiotics are required to manage an underlying bacterial infection or a purulent pericarditis.
- † Immediate pericardial fluid removal for hemodynamic compromise
- ‡ Modify regimen and narrow coverage based on results of culture and susceptibility tests.
- Antifungals are required to manage an underlying fungal infection, (Histoplasmosis is the most common fungal cause pericarditis associated with histoplasmosis mediastinitis.
- 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:
- Cardiac tamponade
- Large, persistent, symptomatic pericardial effusion
- For diagnostic purposes, if there is suspected purulent, tuberculosis, or neoplastic pericarditis.
Management of Recurrent Pericarditis
- Colchicine can be used alone or in conjunction with NSAIDs in prevention and treatment of recurrent pericarditis. Treatment involves an NSAID plus colchicine 2 mg on first day followed by 1 mg daily for three months. A multicenter, double-blind, randomized trial, showed colchicine at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg, in addition to conventional antiinflammatory therapy with aspirin or ibuprofen, reduced the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), as compared with placebo.
- 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.
- 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.
1. Bacterial Pericarditis
- Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Ciprofloxacin 400 mg IV q12h for 28 days
- Alternative regimen (1): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Cefepime 2 g IV q12h for 28 days
- Alternative regimen (2): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days AND Ceftriaxone 2 g IV q24h for 14–42 days
- Note: Pericardiocentesis must be promptly performed. Pericardial drainage combined with effective systemic antibiotic therapy is mandatory (antistaphylococcal agent plus aminoglycoside, followed by tailored antibiotic therapy according to cultures). Frequent irrigation of the pericardial cavity with urokinase or streptokinase may be considered. Open surgical drainage through subxiphoid pericardiotomy is preferable. Pericardiectomy may be required in patients with dense adhesions, loculated and thick purulent effusion, recurrence of tamponade, persistent infection, and progression to constriction.
- 1.3. Pathogen-directed antimicrobial therapy
- 1.3.6. Staphylococcus aureus, methicillin-susceptible
2. Tuberculous Pericarditis.
- Preferred regimen: (Isoniazid 5 mg/kg (300 mg) PO qd AND Rifampicin 10 mg/kg (600 mg) PO qd AND Pyrazinamide 1,500 mg PO qd AND Ethambutol 1,200 mg PO qd for 2 months) THEN (Rifampicin 10 mg/kg (600 mg) PO qd AND Pyrazinamide 1,500 mg PO qd for 4 months) AND Prednisolone 1–2 mg/kg/day for 5–7 days with slow taper over 6–8 weeks.
- Pediatric doses: Isoniazid 10–15 mg/kg (300 mg); Rifampin 10–20 mg/kg (600 mg); Pyrazinamide 15–30 mg/kg (2.0 g); Ethambutol 15–20 mg/kg daily (1.0 g).
- Note: Intrapericardial drainage is done if needed. If constriction develops inspite of medical therapy, pericardiectomy is indicated.
3. Viral pericarditis
- 3.1. CMV pericarditis
- Preferred regimen: Immunoglobulin 1 time per day 4 ml/kg on day 0, 4, and 8; 2 ml/kg on day 12 and 16.
- Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.
- 3.2. Coxsackie B pericarditis
- 3.3. Adenovirus and parvovirus B19 perimyocarditis
4. Fungal Pericarditis
- Empiric therapy : Fluconazole, Ketoconazole, Itraconazole, Amphotericin B, Liposomal amphotericin B or Amphotericin B lipid complex is indicated.
- 4.1. Histoplasmosis
- Preferred regimen: Nonsteroidal anti-inflammatory drugs given during 2–12 weeks.
- 4.2. Nocardiosis
- 4.3. Actinomycosis
2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)
Pericardial Diseases (DO NOT EDIT)
|"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 year. (Level of Evidence: C)"|
2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)
Recommendations for the management of acute pericarditis
|1. Hospital admission is recommended for high-risk patients with acute pericarditis (at least one risk factor).
Recommendations for the treatment of acute pericarditis
|1. Aspirin or NSAIDs are recommended as first-line therapy for acute pericarditis with gastroprotection.
|1. Serum CRP should be considered to guide the treatment length and assess the response to therapy.
2. Low-dose corticosteroids should be considered for acute pericarditis in cases of contraindication/failure of aspirin/NSAIDs and colchicine, and when an infectious cause has been excluded, or when there is a specific indication such as autoimmune disease.
4. For athletes, the duration of exercise restriction should be considered until resolution of symptoms and normalization of CRP, ECG, and echocardiogram—at least 3 months is recommended. (Level of Evidence: C)
|Corticosteroids are not recommended as first-line therapy for acute pericarditis. (Level of Evidence: C)|
Recommendations for the management of recurrent pericarditis
|1. Aspirin and NSAIDs are mainstays of treatment and are recommended at full doses, if tolerated, until complete symptom resolution.
2. Colchicine (0.5 mg twice daily or 0.5 mg daily for patients, 70 kg or intolerant to higher doses); use for 6 months is recommended as an adjunct to aspirin/NSAIDs.(Level of Evidence: A)
|1. Colchicine therapy of longer duration (>6 months) should be considered in some cases, according to clinical response.
5. Exercise restriction should be considered for non-athletes with recurrent pericarditis until symptom resolution and CRP normalization, taking into account the previous history and clinical conditions.
8. If symptoms recur during therapy tapering, the management should consider not increasing the dose of corticosteroids to control symptoms, but increasing to the maximum dose of Aspirin or NSAIDs, well distributed, generally every 8 hours, and intravenously if necessary, adding Colchicine and adding analgesics for pain control. (Level of Evidence: C)
|Corticosteroid therapy is not recommended as a first-line approach.(Level of Evidence: B)|
Recommendations for therapy of constrictive pericarditis
|1. The mainstay of treatment of chronic permanent constriction is pericardiectomy.
|Empiric anti-inflammatory therapy may be considered in cases with transient or new diagnosis of constriction with concomitant evidence of pericardial inflammation (i.e. CRP elevation or pericardial enhancement on CT/CMR). (Level of Evidence: C)|
|For the definited diagnosis of viral pericarditis, a comprehensive workup of histological, cytological, immunohistological and molecular investigations in pericardial fluid and peri-/epicardial biopsies should be considered. (Level of Evidence: C)|
| 1. Routine viral serology is not recommended, with the possible exception of HIV and HCV.
Recommendations for the therapy of purulent pericarditis
|1. Effective pericardial drainage is recommended for purulent pericarditis.|
|1. Subxiphoid pericardiotomy and rinsing of the pericardial cavity should be considered.
3. Pericardiectomy for dense adhesions, loculated or thick purulent effusion, recurrence of tamponade, persistent infection and progression to constriction should be considered. (Level of Evidence: C)
Recommendations for the management of pericarditis in renal failure
|1. Dialysis should be considered in uraemic pericarditis.
|1. Pericardial aspiration and/or drainage may be considered in non-responsive patients with dialysis.
|Colchicine is contraindicated in patients with pericarditis and severe renal impairment. (Level of Evidence: C)|
Recommendations for the diagnosis and management of pericarditis associated with myocarditis
|1. In cases of pericarditis with suspected associated myocarditis, coronary angiography (according to clinical presentation and risk factor assessment) is recommended in order to rule out acute coronary syndromes.
|Empirical anti-inflammatory therapies (lowest efficacious doses) should be considered to control chest pain. (Level of Evidence: C)|
Recommendations for the prevention and management of radiation pericarditis
|1. Radiation therapy methods that reduce both the volume and the dose of cardiac irradiation are recommended whenever
possible.(Level of Evidence: C)
|1. Pericardiectomy should be considered for radiation-induced constrictive pericarditis, but with a worse outcome than when performed for constrictive pericarditis of other causes, because of co-existing myopathy. (Level of Evidence: B)|
Recommendations for therapy of acute and recurrent pericarditis in children
|1. NSAIDs at high doses are recommended as first-line therapy for acute pericarditis in children until complete symptom
| Colchicine should be considered as an adjunct to anti-inflammatory therapy for acute recurrent pericarditis in children:
| Anti-IL-1 drugs may be considered in children with recurrent pericarditis and especially when they are corticosteroid
dependent.(Level of Evidence: C)
| 1. Aspirin is not recommended in children due to the associated risk of Reye’s syndrome and hepatotoxicity.
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