Sandbox pericarditis

Does the patient have high risk features? High risk features include: ❑ Fever >38°C ❑ Leucocytosis ❑ Subacute presentation ❑ Cardiac tamponade ❑ Large pericardial effusion ❑ Elevated troponins (myopericarditis) ❑ Concurrent oral anticoagulation ❑ Lack of response to aspirin or NSAIDs after at least 1 wk of therapy ❑ Immunosuppressed state ❑ Acute trauma ❑ Relapsing pericarditis

Yes

No

Inpatient treatment

Outpatient treatment

Unstable patient ❑ Cardiac tamponade ❑ Hypotension ❑ Pulsus paradoxus ❑ Jugular vein distention

Stable post MI patient

Stable patient without prior MI

Post MI

No previous MI

Treat cardiac tamponade ❑ Immediately transfer the patient to ICU ❑ Perform pericardiocentesis ❑ Monitor telemetry and check vital frequntly ❑ Call cardiology team immediately Initiate medical therapy Administer NSAIDs Avoid NSAIDs in post-MI pericarditis ❑ Ibuprofen (first line) ❑ Orally 300-800 mg TDS or QID x 1-2 weeks ❑ Gradual tapering every 2-3 days, OR ❑ Indomethacin ❑ Orally 50 mg TDS x 1-2 weeks ❑ Gradual tapering every 2-3 days for Rx period of 3-4 weeks OR Administer aspirin ❑ Drug of choice in post-MI pericarditis patients ❑ High-dose aspirin: ❑ Orally 800 mg QID or TDS x 7-10 days ❑ Gradual tapering by 800 mg/week for 3 additional weeks ❑ Stop anticoagulants if patient develops pericardial effusion AND/OR Administer colchicine ❑ Combination with NSAIDs (better response rate) ❑ Can be used alone ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Administer gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) OR ❑ Omeprazole (20 mg/day) Avoid steroids ❑ Avoid steroids to treat an initial episode of pericarditis Order tests to identify the specific etiology ❑ Order specifc tests based on the clinical suspicion ❑ Treat according to the etiology Educate about life style modification ❑ In case of pericarditis, avoid sternous physical activity until symptom resolution ❑ In case of myopericarditis, avoid competitive sports for six months and until normalization of lab findings

Inititate medical therapy Administer High-dose aspirin ❑ Orally 800 mg QID or TDS x 7-10 days ❑ Gradual tapering by 800 mg/week for 3 additional weeks AND/OR Administer Colchicine ❑ In case of poor response to aspirin ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Administer gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) OR ❑ Omeprazole (20 mg/day) Avoid steroids ❑ Avoid steroids to treat an initial episode of pericarditis ❑ Stop anticoagulants if the patient develops pericardial effusion Order tests to identify the specific etiology ❑ Order specifc tests based on the clinical suspicion ❑ Treat according to the etiology Educate about life style modification ❑ In case of pericarditis, avoid sternous physical activity until symptom resolution ❑ In case of myopericarditis, avoid competitive sports for six months and until normalization of lab findings

Initiate medical therapy Administer NSAIDs (First line) ❑ Ibuprofen (first line) ❑ Orally 300-800 mg TDS or QID x 1-2 weeks ❑ Gradual tapering every 2-3 days, OR ❑ Indomethacin ❑ Orally 50 mg TDS x 1-2 weeks ❑ Gradual tapering every 2-3 days for Rx period of 3-4 weeks AND/OR Administer Colchicine ❑ Combination with NSAIDs (better response rate) ❑ Can be used alone ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Administer gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) OR ❑ Omeprazole (20 mg/day) Avoid steroids ❑ Avoid steroids in an initial episode of pericarditis Order tests to identify the specific etiology ❑ Order specifc tests based on the clinical suspicion ❑ Treat according to the etiology Order pericardiocentesis in case of ❑ High suspicion of purulent or neoplastic pericarditis ❑ Effusions > 20 mm in echocardiography in diastole ❑ Large or symptomatic effusions despite one week of medical therapy Educate about life style modification ❑ In case of pericarditis, avoid sternous physical activity until symptom resolution ❑ In case of myopericarditis, avoid competitive sports for six months and until normalization of lab findings

Intitate medical therapy Administer High-dose aspirin ❑ Orally 800 mg QID or TDS x 7-10 days ❑ Gradual tapering by 800 mg/week for 3 additional weeks AND/OR Administer Colchicine ❑ In case of poor response to aspirin ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Administer gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) OR ❑ Omeprazole (20 mg/day) Avoid steroids ❑ Avoid steroids to treat an initial episode of pericarditis ❑ Stop anticoagulants if the patient develops pericardial effusion Order tests to identify the specific etiology ❑ Order specifc tests based on the clinical suspicion ❑ Treat according to the etiology Educate about life style modification ❑ In case of pericarditis, avoid sternous physical activity until symptom resolution ❑ In case of myopericarditis, avoid competitive sports for six months and until normalization of lab findings

Initiate medical therapy Administer NSAID's ❑ Ibuprofen ❑ Preferred ❑ Orally 300-800 mg TDS or QID x 1-2 weeks ❑ Gradual tapering every 2-3 days, OR ❑ Indomethacin ❑ Orally 50 mg TDS x 1-2 weeks ❑ Gradual tapering every 2-3 days for Rx period of 3-4 weeks AND/OR Colchicine ❑ Combination with NSAIDs (better response rate) ❑ Can be used alone ❑ Orally 0.5 mg BID x 3 months (>70 kg) ❑ Orally 0.5 mg OD x 3 months (≤70 kg) Administer gastroprotective agents ❑ Misoprostol (600 to 800 mg/day) OR ❑ Omeprazole (20 mg/day) Avoid steroids ❑ Avoid steroids to treat an initial episode of pericarditis Educate about life style modification ❑ In case of pericarditis, avoid sternous physical activity until symptom resolution ❑ In case of myopericarditis, avoid competitive sports for six months and until normalization of lab findings

Assess response to treatment

Response

No response

Follow up as outpatient

Admit to the hospital