Sandbox pericarditis: Difference between revisions

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❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
| E02= '''Initiate medical therapy'''<br>
| E02= '''Inititate medical therapy'''<br>
'''''Administer [[aspirin|High-dose aspirin]]'''''  <br>
:❑ Orally 800 mg QID or TDS x 7-10 days<BR>
:❑ Gradual tapering by 800 mg/week for 3 additional weeks <br>
 
<br> '''AND/OR'''<br>
 
'''''Administer [[Colchicine]]'''''  <br>
❑ In case of poor response to aspirin <ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334  }} </ref> <br>❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR>
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR>
 
'''''Administer gastroprotective agents'''''  <br>
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR>
:❑ [[Omeprazole]] (20 mg/day)  <br>
 
'''''Avoid [[steroids]]'''''<br>
❑ Avoid steroids to treat an initial episode of pericarditis  <br>
 
❑ Stop [[anticoagulants]] if the patient develops [[pericardial effusion]]  <br>
 
----
'''Order tests to identify the specific etiology'''<br>
❑ [[Pericarditis resident survival guide#Treatment#Etiology Specific Management|Order specifc tests based on the clinical suspicion]]<br>
❑ [[Pericarditis resident survival guide#Treatment#Etiology Specific Management|Treat according to the etiology]]
----
'''Educate about life style modification'''<br>
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
| E03=
'''Initiate medical therapy'''<br>
'''''Administer [[NSAIDs]] (First line)'''''<br>
'''''Administer [[NSAIDs]] (First line)'''''<br>
❑ [[Ibuprofen]] (first line)<br>
❑ [[Ibuprofen]] (first line)<br>
Line 112: Line 141:
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
| E03= '''Initiate medical therapy'''<br>
| E04=  
'''Initiate medical therapy'''<br>
'''''Administer  NSAID's'''''<br>
'''''Administer  NSAID's'''''<br>
❑ [[Ibuprofen]] <br>
❑ [[Ibuprofen]] <br>
Line 141: Line 171:
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings
| E04= | E05= }}
| E05= '''Intitate medical therapy'''<br>
'''''Administer [[aspirin|High-dose aspirin]]'''''  <br>
:❑ Orally 800 mg QID or TDS x 7-10 days<BR>
:❑ Gradual tapering by 800 mg/week for 3 additional weeks <br>
 
<br> '''AND/OR'''<br>
 
'''''Administer [[Colchicine]]'''''  <br>
❑ In case of poor response to aspirin <ref name="pmid24552334">{{cite journal| author=Goldfinger S| title=A randomized trial of colchicine for acute pericarditis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 8 | pages= 780 | pmid=24552334 | doi=10.1056/NEJMc1315351#SA1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24552334  }} </ref> <br>❑ Orally 0.5 mg BID x 3 months (>70 kg)<BR>
❑ Orally 0.5 mg OD x 3 months (≤70 kg) <BR>
 
'''''Administer gastroprotective agents'''''  <br>
:❑ [[Misoprostol]] (600 to 800 mg/day)<BR>OR<BR>
:❑ [[Omeprazole]] (20 mg/day)  <br>
 
'''''Avoid [[steroids]]'''''<br>
❑ Avoid steroids to treat an initial episode of pericarditis  <br>
 
❑ Stop [[anticoagulants]] if the patient develops [[pericardial effusion]]  <br>
 
----
'''Order tests to identify the specific etiology'''<br>
❑ [[Pericarditis resident survival guide#Treatment#Etiology Specific Management|Order specifc tests based on the clinical suspicion]]<br>
❑ [[Pericarditis resident survival guide#Treatment#Etiology Specific Management|Treat according to the etiology]]
----
'''Educate about life style modification'''<br>
❑ In case of [[pericarditis]], avoid sternous physical activity until symptom resolution<br>
❑ In case of [[myopericarditis]], avoid competitive sports for six months and until normalization of lab findings}}
{{Family tree| | | | | | | | | | | | | | |!| |!| | | }}
{{Family tree| | | | | | | | | | | | | | |!| |!| | | }}
{{Family tree| | | | | | | | | | | | | | | F01 | | | F01= }}
{{Family tree| | | | | | | | | | | | | | | F01 | | | F01= Assess response to treatment}}
{{Family tree| | | | | | | | | | | | | |,|-|^|-|.| | }}
{{Family tree| | | | | | | | | | | | | |,|-|^|-|.| | }}
{{Family tree| | | | | | | | | | | | | G01 | | G02 | G01= | G02= }}
{{Family tree| | | | | | | | | | | | | G01 | | G02 | G01= Response| G02= No response}}
{{Family tree| | | | | | | | | | | | | |!| | | |!| | }}
{{Family tree| | | | | | | | | | | | | H01 | | H02 | H01= Follow up as outpatient| H02= Admit to the hospital}}
{{Family tree/end}}
{{Family tree/end}}

Revision as of 22:34, 5 April 2014

 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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)[1]
❑ 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 [1]
❑ 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)[1]
❑ 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
 
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)[1]
❑ 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
 
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 [1]
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess response to treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Response
 
No response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up as outpatient
 
Admit to the hospital
  1. 1.0 1.1 1.2 1.3 1.4 Goldfinger S (2014). "A randomized trial of colchicine for acute pericarditis". N Engl J Med. 370 (8): 780. doi:10.1056/NEJMc1315351#SA1. PMID 24552334.