Pericarditis: Difference between revisions

(Text replacement - "0 mg" to "0mg")
(Text replacement - "5 mg" to "5mg")
Line 97: Line 97:
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
**[[Ibuprofen]] 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Glucocorticoid therapy''' for patients with contraindications to [[NSAIDs]]
*'''Glucocorticoid therapy''' for patients with contraindications to [[NSAIDs]]
**[[Prednisone]] 0.2 to 0.5 mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>
**[[Prednisone]] 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering<ref>Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.</ref>


===Recurrent or Refractory===
===Recurrent or Refractory===
Line 111: Line 111:
*Neoplastic pericarditis
*Neoplastic pericarditis
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Liver disease or aminotransferase levels ≥1.5x upper limits of normal
*Creatinine >2.5 mg/dL (>221 umol/L)
*Creatinine >2.5mg/dL (>221 umol/L)
*Myopathy or CK > upper limits of normal
*Myopathy or CK > upper limits of normal
*Inflammatory bowel disease
*Inflammatory bowel disease

Revision as of 16:03, 24 July 2016

Background

Pericarditis compared with normal pericardium

Etiology

Clinical Features

Differential Diagnosis

ST Elevation

Diagnosis

Work-Up

  • ECG
  • Labs
    • WBC, ESR, trop
  • CXR
  • Bedside Ultrasound to r/o effusion

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression
  • Classically described to cause diffuse ST elevations
  • Less reliable in post-MI patients and those with baseline ECG abnormalities
  • May see low voltage/alternans if effusion present
  • If early repol confounding interpretation check ST:T ratio
    • If (ST elev)/(T height) in V6 or I >0.25 likely pericarditis
  • If predominantly inferior elevation, depression in aVL is sensitive for STEMI[2]

Stages of Progression

Stages of pericarditis
PTa depression
  • Stage I:
    • Global concave up ST elevation in all leads (esp V4-6, I, II) in all leads except in aVR, V1 and III
    • PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
  • Stage II:
    • "pseudonormalisation," ST to baseline, big T's, PR dep
  • Stage III:
    • T wave flatten then inversion
  • Stage IV:
    • Return to baseline

STEMI vs Pericarditis

MI Pericarditis
no fever

fever

pain varies w/motion

focal ST chgs diffuse ST elev
reciprocal chgs no reciprocal chgs
Q waves no Q wave
+/- pulm edema clear lungs
wall motion abn nl wall motion

Management

Initial Treatment

  • NSAIDS or Aspirin (ASA) are usually first line treatment for viral or idiopathic pericarditis.[3]
    • Aspirin 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    • Ibuprofen 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  • Glucocorticoid therapy for patients with contraindications to NSAIDs
    • Prednisone 0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering[4]

Recurrent or Refractory

For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[5]

  • Colchicine
    • Patients >70kg - 0.6mg PO BID x 3 months
    • Patients<70kg - 0.6mg PO Daily x 3 months
    • If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.

Contraindications to Colchicine[6]

  • Tuberculous
  • Neoplastic pericarditis
  • Liver disease or aminotransferase levels ≥1.5x upper limits of normal
  • Creatinine >2.5mg/dL (>221 umol/L)
  • Myopathy or CK > upper limits of normal
  • Inflammatory bowel disease
  • Life expectancy ≤18 months
  • Pregnancy or lactation

Uremic Pericarditis

  • The definitive treatment is dialysis

Tamponade

Disposition

  • Hospitalization is not necessary in most cases
  • Consider admission for:
    • Subacute onset over weeks
    • Fever >100.4
    • Large effusion (echo-free space>20mm)
    • Immunosupressed
    • Anticoagulant use
    • Failure to respond to NSAIDs (>7dy)
    • Elevated cardiac enzymes

Complications

  • Pericardial Effusion and Tamponade
  • Recurence
    • Usually weeks to months after initial episode
    • Management is same
  • Contrictive Pericarditis
    • Restrictive picture with pericardial calcifications on CXR, thickened on TTE
    • Treat with pericardial window

See Also

References

  1. ↑ LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
  2. ↑ Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016; 34(2):149-154.
  3. ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
  4. ↑ Imazio M, Brucato A, Cumetti D, et al. Corticosteroids for recurrent pericar- ditis: high versus low doses: a nonran- domized observation. Circulation 2008; 118:667-71.
  5. ↑ Imazio M.Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005 Sep 26;165(17):1987-91.
  6. ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF
Retrieved from "https://www.wikem.org/w/index.php?title=Pericarditis&oldid=89309"