INDEX

    Pericarditis – Treatment

    Cardiovascular, Inflammatory

    Last Updated Jul 13, 2020
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    Context

    • True incidence of pericarditis unknown: 5% of non-ACS “chest pain” ED visits.
    • Cardiac tamponade can occur in up to 15% of cases.
    • Important to distinguish from ACS.
    • Inflammatory condition of the pericardium:
      • Infectious etiologies
        • Most common cause is viral or idiopathic as etiologic agent is rarely identified.
        • Consider tuberculosis if recent travel to an endemic region.
      • Non-infectious etiologies
        • Autoimmune conditions – SLE, RA, scleroderma, sarcoid, vasculitis.
        • Autoinflammatory pericardial syndromes (Dressler syndrome): post myocardial infarction, cardiac surgery or cardiac trauma.
        • Neoplastic: (metastatic: lung>breast>leukaemia and lymphoma>melanoma).
        • Radiation.
        • Metabolic (uremia).
        • Drug-related.
      • Symptoms usually last 4-6 weeks but other forms exist
        • Incessant pericarditis: up to 3 months.
        • Recurrent/relapsing pericarditis: symptoms recur after a symptom-free period.
        • Chronic pericarditis: symptoms > 3 months.

    Disposition

    • Outpatient management is recommended for low-risk patients who have no criteria for hospital admission.
    • Consider admission/same-day consult:
      • For diagnosis or etiologic ambiguity: Underlying etiology unlikely to be viral/idiopathic.
      • Myocarditis or myopericarditis (significant troponin elevation).
      • Significant abnormal vital signs or tachycardia out of proportion to pain/fever.
      • Large pericardial effusion (> 20 mm on echo).
      • Relapsing/recurrent, incessant or chronic pericarditis.
      • Figure 2 below outlines triage scheme of pericarditis.

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    Figure 1: Proposed triage scheme for management of pericarditis as per the 2015 European Society of Cardiology Guidelines on diagnosis and management of pericardial disease.
    Source: Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318

     

     

    Recommended Treatment of Acute Pericarditis

    • Restrict physical activity (minimal activity) until resolution of symptoms and normalization of CRP.
    • Treat underlying condition (ex. Antibiotics for purulent pericarditis).
    • First line treatment
      • NSAIDs OR Aspirin + Colchicine.
      • Recommend GI protection with PPI.
    • Second line treatment
      • Prednisone + Colchicine.
        • In retrospective studies steroids associated with higher recurrence rate.
        • Only use steroids if contraindications to NSAIDs/Aspirin or specific indication (ex. systemic inflammatory disease).

    Dosing

    • NSAIDs
      • Ibuprofen 600-800 mg po q8h.
        • 7-14 days, then taper by 200-400 mg every 1-2 weeks.
      • Aspirin 750 to 1000 mg po TID in patients with concomitant CAD.
        • 7-14 days, then taper by 250-500 mg every 1-2 weeks.
    • Colchicine
      • Patients > 70 kg: 0.5 mg PO BID.
      • Patients < 70 kg: 0.5 mg PO daily.
      • Duration: 3 months.
        • Tapering not required.
    • Prednisone
      • 0.2-0.5 mg/kg/day PO.
      • Slow taper recommended (see table in Figure 1).
      • Requires exclusion of infectious (bacteria / TB) etiology.

    Figure 2: Recommended tapering schedule of prednisone based on starting dose.
    Source: Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318

    Procedural/Surgical

    • If there is high clinical suspicion for cardiac tamponade, drainage of the pericardial fluid is required urgently.
      • Needle pericardiocentesis with FAST US, echocardiographic or fluoroscopic guidance.
      • Surgical drainage.
    • See emergent pericardiocentesis video: Emergency Pericardiocentesis.

    Criteria For Transfer To Another Facility

    • Site/region specific.
    • Consider hemodynamic stability and length of travel prior to transport.

    Criteria For Safe Discharge Home

    • Follow up with primary care provider (unless consultant involved) within 7 days to ensure adequate response to treatment and monitoring of CRP.

    Prognosis

    • Prognosis for acute viral/idiopathic pericarditis is quite good with treatment.
      • Cardiac tamponade rarely occurs.
      • Constrictive pericarditis develops in less than 1%.

    Quality Of Evidence?

    Justification

    Recommendation for Aspirin or NSAID + Colchicine for first line treatment of acute pericarditis.

    High

    Recommendation for outpatient management for low risk patients and hospital admission for high risk patients with at least one risk factor.

    Moderate

    Use of CRP and resolution of symptoms to guide return to physical activity.

    Low

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