Pericarditis: Difference between revisions
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{{ST elevation DDX}}
{{ST elevation DDX}}
==Management==
===Initial Treatment===
*'''NSAIDS or Aspirin (ASA)''' are usually first line treatment for viral or idiopathic pericarditis.<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
**[[Aspirin]] 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks  OR
**[[Ibuprofen]] 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
*'''Glucocorticoid therapy''' for patients 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>


==Initial Treatment==
===Recurrent or Refractory===
#'''NSAIDS Aspirin (ASA)'''are usual first line treatment for viral or idiopathic pericarditis.  Two options both have tapering doses:<ref>Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 [http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208536 PDF]</ref>
##Aspirin 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks  OR
##Ibuprofen 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
#'''Glucocorticoid therapy''' for patients 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>
 
==Recurrent or Refractory==
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>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.</ref>
''For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line''<ref>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.</ref>


#'''Colchicine'''
*'''[[Colchicine]]'''
#Patients >70kg - 0.6mg PO BID x3months
**Patients >70kg - 0.6mg PO BID x3months
#Patients<70kg - 0.6mg PO Daily 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.
**If patients develop serious diarrhea decrease their dosing to the next weight class or stop treatment.


===Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>===
====Contraindications to Colchicine<ref>Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.[http://circ.ahajournals.org/content/121/7/916.long PDF] </ref>====
*Tuberculous
*Tuberculous
*Neoplastic pericarditis
*Neoplastic pericarditis
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*Pregnancy or lactation
*Pregnancy or lactation


==Uremic Pericarditis==
===Uremic Pericarditis===
The definitive treatment is dialysis
*The definitive treatment is dialysis


==[[Pericardial effusion and tamponade|Tamponade]]==
===[[Pericardial effusion and tamponade|Tamponade]]===
#Tamponade requires  [[Pericardiocentesis]]
*Tamponade requires  [[Pericardiocentesis]]


== Disposition ==
== Disposition ==
#Hospitalization is not necessary in most cases
*Hospitalization is not necessary in most cases
#Consider admission for:
*Consider admission for:
##Subacute onset over weeks
**Subacute onset over weeks
##Fever >100.4
**[[Fever]] >100.4
##Large effusion (echo-free space>20mm)
**Large effusion (echo-free space>20mm)
##Immunosupressed
**Immunosupressed
##Anticoagulant use
**Anticoagulant use
##Failure to respond to NSAID Rx (>7dy)
**Failure to respond to [[NSAID]] Rx (>7dy)


== Complications ==
== Complications ==
#[[Pericardial Effusion and Tamponade]]
*[[Pericardial Effusion and Tamponade]]
#Recurence
*Recurence
##Usually weeks to months after initial episode
**Usually weeks to months after initial episode
##Management is same
**Management is same
#Contrictive Pericarditis
*Contrictive Pericarditis
##Restrictive picture with pericardial calcifications on CXR, thickened on TTE
**Restrictive picture with pericardial calcifications on CXR, thickened on TTE
##Rx with pericardial window
**Treat with pericardial window


==See Also==
==See Also==
*[[ST segment elevation]]
*[[ST segment elevation]]
[[Category:Cards]]


==Sources==
==Sources==
<references/>
<references/>
[[Category:Cards]]

Revision as of 12:55, 3 February 2015

Background

Etiology

  1. Idiopathic (25-85%)
  2. Infection (up to 20%, including viral, bacterial, TB)
  3. Malignancy: heme, lung, breast
  4. Uremia
  5. Post radiation
  6. Connective tissue dz
  7. Drugs: procainamide, hydralaine, methyldopa, anticoagulants
  8. Cardiac injury (can see up to weeks later): post MI, trauma, aortic dissection

Diagnosis

Clinical Features

  1. Pleuritic chest pain
    1. Radiates to chest, back, left trapezius
    2. Diminishes w/ sitting up/leaning forward
  2. SOB
    1. Esp if concommitant pleural effusion
  3. Hypotension/extremis if cardiac tamponade
  4. Fever
  5. Friction rub

ECG

Acute pericarditis with clear diffuse ST elevation and some PTa depression
  • ECG
    • Less reliable in post-MI pts and those w/ 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

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

Work-Up

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

Differential Diagnosis

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

ST Elevation

Management

Initial Treatment

  • NSAIDS or Aspirin (ASA) are usually first line treatment for viral or idiopathic pericarditis.[1]
    • Aspirin 800 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks OR
    • Ibuprofen 600 mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
  • Glucocorticoid therapy for patients contraindications to NSAIDs
    • Prednisone 0.2 to 0.5 mg/kg of body weight per day for 2 weeks with gradual tapering[2]

Recurrent or Refractory

For recurrent or refractory cases consider colchicine and or steroids although literature suggests it can be used as first line[3]

  • Colchicine
    • Patients >70kg - 0.6mg PO BID x3months
    • 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[4]

  • Tuberculous
  • Neoplastic pericarditis
  • Liver disease or aminotransferase levels ≥1.5x upper limits of normal
  • Creatinine >2.5 mg/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 NSAID Rx (>7dy)

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

Sources

  1. ↑ Imazio M. A randomized trial of colchicine for acute pericarditis.N Engl J Med. 2013 Oct 17;369(16):1522-8 PDF
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Imazio M. Controversial issues in the management of pericardial diseases.Circulation. 2010 Feb 23;121(7):916-28.PDF
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