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Failure to respond to [[NSAIDs]] within one week (as indicated by persistence of [[fever]], a worsening of symptoms such as [[chest pain]], the development of a new [[pericardial effusion]]), likely indicates that the underlying cause may not be viral or idiopathic in nature. These patients may require re-evaluation, observation, and more aggressive therapy as described in the next section.
Failure to respond to [[NSAIDs]] within one week (as indicated by persistence of [[fever]], a worsening of symptoms such as [[chest pain]], the development of a new [[pericardial effusion]]), likely indicates that the underlying cause may not be viral or idiopathic in nature. These patients may require re-evaluation, observation, and more aggressive therapy as described in the next section.
===Colchicine===
===Colchicine===
In the European guidelines, [[colchicine]] carries a [[ACC AHA guidelines classification scheme#Classification of Recommendations|class IIa]] recommendation for the treatment of an initial episode of pericarditis along with an [[NSAID]]. The dose is 0.6 mg bid for 3 months. It should be noted that a long term treatment of colchicine for several weeks or months should be considered, even after disappearance of effusion.<ref name="Imazio-2012">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Brucato | first2 = A. | last3 = Forno | first3 = D. | last4 = Ferro | first4 = S. | last5 = Belli | first5 = R. | last6 = Trinchero | first6 = R. | last7 = Adler | first7 = Y. | title = Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. | journal = Heart | volume = 98 | issue = 14 | pages = 1078-82 | month = Jul | year = 2012 | doi = 10.1136/heartjnl-2011-301306 | PMID = 22442198 }}</ref> <ref name="Imazio-2005">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Bobbio | first2 = M. | last3 = Cecchi | first3 = E. | last4 = Demarie | first4 = D. | last5 = Demichelis | first5 = B. | last6 = Pomari | first6 = F. | last7 = Moratti | first7 = M. | last8 = Gaschino | first8 = G. | last9 = Giammaria | first9 = M. | title = Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. | journal = Circulation | volume = 112 | issue = 13 | pages = 2012-6 | month = Sep | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.542738 | PMID = 16186437 }}</ref> The rate of recurrence is lowered with [[colchicine]] therapy from 32.3% to 10.7%. In a multicenter, double-blind trial, the use of [[colchicine]] at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg in acute pericarditis, when added to conventional antiinflammatory therapy with [[aspirin]] or [[ibuprofen]], significantly reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), the hospitalization rate (5.0% vs. 14.2%, P = 0.02), and the remission rate at 1 week (85.0% vs. 58.3%, P<0.001), as compared with placebo.<ref name="Imazio-2013">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Brucato |first2 = A. | last3 = Cemin | first3 = R. | last4 = Ferrua | first4 = S. | last5 = Maggiolini | first5 = S. | last6 = Beqaraj | first6 = F. | last7 = Demarie | first7 = D.| last8 = Forno | first8 = D. | last9 = Ferro | first9 = S. | title = A Randomized Trial of Colchicine for Acute Pericarditis. | journal = N Engl J Med | volume =  | issue =  | pages =  | month = Aug | year = 2013 | doi = 10.1056/NEJMoa1208536 | PMID = 23992557 }}</ref>
In the European guidelines, [[colchicine]] carries a [[ACC AHA guidelines classification scheme#Classification of Recommendations|class IIa]] recommendation for the treatment of an initial episode of pericarditis along with an [[NSAID]]. The dose is 0.6 mg bid for 3 months. It should be noted that a long term treatment of colchicine for several weeks or months should be considered, even after disappearance of effusion.<ref name="Imazio-2012">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Brucato | first2 = A. | last3 = Forno | first3 = D. | last4 = Ferro | first4 = S. | last5 = Belli | first5 = R. | last6 = Trinchero | first6 = R. | last7 = Adler | first7 = Y. | title = Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. | journal = Heart | volume = 98 | issue = 14 | pages = 1078-82 | month = Jul | year = 2012 | doi = 10.1136/heartjnl-2011-301306 | PMID = 22442198 }}</ref> <ref name="Imazio-2005">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Bobbio | first2 = M. | last3 = Cecchi | first3 = E. | last4 = Demarie | first4 = D. | last5 = Demichelis | first5 = B. | last6 = Pomari | first6 = F. | last7 = Moratti | first7 = M. | last8 = Gaschino | first8 = G. | last9 = Giammaria | first9 = M. | title = Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. | journal = Circulation | volume = 112 | issue = 13 | pages = 2012-6 | month = Sep | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.542738 | PMID = 16186437 }}</ref>
 
The rate of recurrence after an initial episode is lowered with [[colchicine]] therapy by approximately 50% - from 26% to 14% (see [http://www.wikidoc.org/index.php/File:Colchicine_for_the_prevention_of_pericarditis_and_the_pospericardiotomy_syndrome.png Forest plot]).<ref>Colchicine for pericarditis: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Colchicine-for-Pericarditis/. Accessed November 16, 2014.</ref>
 
[[Image:Colchicine_for_the_prevention_of_pericarditis_and_the_pospericardiotomy_syndrome.png|400px]]
 
For example, in a multicenter, double-blind trial, the use of [[colchicine]] at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg in acute pericarditis, when added to conventional antiinflammatory therapy with [[aspirin]] or [[ibuprofen]], significantly reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), the hospitalization rate (5.0% vs. 14.2%, P = 0.02), and the remission rate at 1 week (85.0% vs. 58.3%, P<0.001), as compared with placebo.<ref name="Imazio-2013">{{Cite journal  | last1 = Imazio | first1 = M. | last2 = Brucato |first2 = A. | last3 = Cemin | first3 = R. | last4 = Ferrua | first4 = S. | last5 = Maggiolini | first5 = S. | last6 = Beqaraj | first6 = F. | last7 = Demarie | first7 = D.| last8 = Forno | first8 = D. | last9 = Ferro | first9 = S. | title = A Randomized Trial of Colchicine for Acute Pericarditis. | journal = N Engl J Med | volume =  | issue =  | pages =  | month = Aug | year = 2013 | doi = 10.1056/NEJMoa1208536 | PMID = 23992557 }}</ref>


===Steroids===
===Steroids===

Revision as of 22:17, 16 November 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Ahmed Zaghw, M.D. [3]

Overview

The management of pericarditis depends upon whether the patient has an uncomplicated or a complicated disease course. Uncomplicated pericarditis is generally treated with non-steroidal anti-inflammatory drugs such as ibuprofen in case of viral or idiopathic pericarditis and aspirin in case of post-MI pericarditis. Pericarditis complicated with effusion or cardiac tamponade is generally treated with urgent pericardiocentesis in case of cardiac tamponade, antibiotics in case of purulent pericardial effusion, and steroids or colchicine in patients with recurrent or refractory disease.

Management of Uncomplicated Pericarditis

Patients with uncomplicated acute pericarditis can generally be treated and followed up in an outpatient clinic. The treatment of viral or idiopathic pericarditis is with non-steroidal anti-inflammatory drugs. Patients should be observed for side effects since NSAIDs are known to affect the GI mucosa. If the underlying cause of pericarditis is something other than a viral cause, the specific etiology should be treated.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are the mainstay of therapy for uncomplicated pericarditis (viral or idiopathic pericarditis). The goal of therapy is to reduce pain and inflammation. While symptoms are improved by NSAIDs, the duration of the episode may not be reduced. The preferred NSAID is ibuprofen which has a large range of doses that can be titrated to the patient's tolerance.[1] Depending on the severity of symptoms, the dosing is between 300-800 mg every 6-8 hours for days or weeks as needed. In order to minimize a recurrence of symptoms, a slow tapering of the NSAID dose may be required. As with all NSAID use, GI prophylaxis should be strongly recommended. Gastroprotection with misoprostol (600 to 800 g/day) or omeprazole (20 mg/day) is highly recommended.[2] The gastroprotection recommendation is based on several studies have evaluated factors that place patients at increased risk of gastroduodenal toxicity from NSAIDs.[3]

The American College of Gastroenterology identified the five most important risk factors for gastroduodenal toxicity:

  • Age 60 years (relative risk [RR] 5.52)
  • History of an adverse gastroduodenal event (RR 4.76)
  • High-dosage NSAIDs (more than twice normal; RR 10.1)
  • Concurrent use of glucocorticoids (RR 4.4)
  • Concurrent use of anticoagulants (RR 12.7).[4]

Patients with several risk factors are at highest risk of NSAID-induced gastroduodenal toxicity.

Aspirin Therapy

An alternative therapy is aspirin 800 mg every 6-8 hours.[5]

Post-MI Pericarditis

In pericarditis following acute myocardial infarction, NSAIDs other than aspirin should be avoided since they can impair scar formation.

Failure to Respond to a Week of Traditional Therapy

Failure to respond to NSAIDs within one week (as indicated by persistence of fever, a worsening of symptoms such as chest pain, the development of a new pericardial effusion), likely indicates that the underlying cause may not be viral or idiopathic in nature. These patients may require re-evaluation, observation, and more aggressive therapy as described in the next section.

Colchicine

In the European guidelines, colchicine carries a class IIa recommendation for the treatment of an initial episode of pericarditis along with an NSAID. The dose is 0.6 mg bid for 3 months. It should be noted that a long term treatment of colchicine for several weeks or months should be considered, even after disappearance of effusion.[6] [7]

The rate of recurrence after an initial episode is lowered with colchicine therapy by approximately 50% - from 26% to 14% (see Forest plot).[8]

For example, in a multicenter, double-blind trial, the use of colchicine at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg in acute pericarditis, when added to conventional antiinflammatory therapy with aspirin or ibuprofen, significantly reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), the hospitalization rate (5.0% vs. 14.2%, P = 0.02), and the remission rate at 1 week (85.0% vs. 58.3%, P<0.001), as compared with placebo.[9]

Steroids

Steroids are not used to treat an initial episode of pericarditis. They provide rapid relief in pain, but are associated with a high rate of recurrence.

Identification of High Risk or Complicated Pericarditis

Patients at high risk of developing complications of pericarditis may required admission to an inpatient service for careful observation for hemodynamic compromise. High risk patients include those with:[5]

Management of Complicated Pericarditis

Drainage in most of cases for culture and local antibiotics †
PLUS
Primary Systemic Regimens in Bacterial Pericarditis ‡
Vancomycin: 15-20 mg/kg q8-12h (target troughs of 15-20 μg/mL) x ???? wks
PLUS
Ceftriaxone: 2 gm IV q24h x ??? wks
or
Cefepime: 2 gm IV q12h x ??? wks
Alternative Systemic Regimens in Bacterial Pericarditis
Vancomycin: 15-20 mg/kg q8-12h (target troughs of 15-20 μg/mL) x ??? wks
PLUS
Ciprofloxacin: 750 mg po bid or 400 mg IV bid
† Immediate pericardial fluid removal for hemodynamic compromise
‡ Modify regimen and narrow coverage based on results of culture and susceptibility tests.
Mild Histoplasmosis Pericarditis
Ibuprofen: 300-800 mg q 6-8 hrs x 1-2 wks as needed, to be tapered †
OR
Indomethacin: 50 mg q8 hrs x 1-2 wks as needed, to be tapered
PLUS
Colchicine: 0.5 to 0.6 mg two times daily x 3 months
NSAID Non-Responders or Hemodynamic Compromise Histoplasmosis Pericarditis
Prednisone: 1 mg/kg po daily tapered over 1–2 wks
PLUS
Itraconazole: 200 mg po 3 times daily x 3 days, then twice daily x 6–12 wks)
PLUS
Pericardial fluid removal for hemodynamic compromise

Management of Cardiac Tamponade and Large Pericardial Effusion

Pericardiocentesis is an invasive procedure in which the pericardial fluid is drained through a needle. A pericardial window is a surgical procedure to drain fluid form the pericardium. Indications for a pericardiocentesis or a pericardial window include the following:[1]

Management of Recurrent Pericarditis

  • Colchicine can be used alone or in conjunction with NSAIDs in prevention and treatment of recurrent pericarditis. Treatment involves an NSAID plus colchicine 2 mg on first day followed by 1 mg daily[4] for three months.[12][13][14] A multicenter, double-blind, randomized trial, showed colchicine at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg, in addition to conventional antiinflammatory therapy with aspirin or ibuprofen, reduced the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), as compared with placebo.[9]
  • Corticosteroids are usually used in those cases that are clearly refractory to NSAIDs and colchicine and a specific cause has not been found. Systemic corticosteroids are usually reserved for those with autoimmune disease. Steroids are sometimes used in post-operative pericarditis as well.
  • Pericardiectomy can be performed if the patient is refractory to medical therapy as a last resort. Most patients will respond to 2 to 3 months of aggressive medical therapy.

Pericarditis Drug Dosage Summary [1]

Drug Dosage in Uncomplicated Pericarditis
Ibuprofen ¶: 300-800 mg q 6-8 hrs x 1-2 wks as needed, to be tapered †
OR
Indomethacin: 50 mg q8 hrs x 1-2 wks as needed, to be tapered ‡
PLUS
Colchicine ~¡: 0.5 to 0.6 mg two times daily x 3 months
Drug Dosage in Post-MI Pericarditis
Aspirin: 650 to 1000 mg q 8 hrs x 1-2 wks as needed, to be tapered ¥
PLUS
Colchicine ~¡: 0.5 to 0.6 mg two times daily x 3 months
Drug Dosage in Refractory Pericarditis or Contraindication to NSAID Therapy
Prednisone: 0.25 to 0.5 mg/kg/day x 2 wks, to be tapered gradually
PLUS
Colchicine ~¡: 0.5 to 0.6 mg two times daily x 3 months
¶ Some patients may require ibuprofen every six hours (four times daily), in which case the dose should not exceed 600 mg every six hours.
† To be tapered by 200 to 400 mg every two to three days once patient is symptom-free.
‡ To be tapered by 25 to 50 mg every two to three days once patient is symptom-free.
¥ To be tapered by 500 to 650 mg every two to three days once patient is symptom-free.
~ Colchicine dose should be reduced to 0.5 to 0.6 mg once daily in patients <70 kg.
¡ 0.5 mg colchicine is not available in US. It is widely available elsewhere.

2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)[15]

Pericardial Diseases (DO NOT EDIT)[15]

Class I
"1. Ventricular arrhythmias that develop in patients with pericardial disease should be treated in the same manner that such arrhythmias are treated in patients with other diseases including ICD and pacemaker implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: C)"

References

  1. 1.0 1.1 1.2 Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology". Eur Heart J. 25 (7): 587–10. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
  2. Imazio, M.; Demichelis, B.; Parrini, I.; Giuggia, M.; Cecchi, E.; Gaschino, G.; Demarie, D.; Ghisio, A.; Trinchero, R. (2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J Am Coll Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364. Unknown parameter |month= ignored (help)
  3. Gabriel, SE.; Jaakkimainen, L.; Bombardier, C. (1991). "Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis". Ann Intern Med. 115 (10): 787–96. PMID 1834002. Unknown parameter |month= ignored (help)
  4. Lanza, FL. (1998). "A guideline for the treatment and prevention of NSAID-induced ulcers. Members of the Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology". Am J Gastroenterol. 93 (11): 2037–46. doi:10.1111/j.1572-0241.1998.00588.x. PMID 9820370. Unknown parameter |month= ignored (help)
  5. 5.0 5.1 Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J Am Coll Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
  6. Imazio, M.; Brucato, A.; Forno, D.; Ferro, S.; Belli, R.; Trinchero, R.; Adler, Y. (2012). "Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis". Heart. 98 (14): 1078–82. doi:10.1136/heartjnl-2011-301306. PMID 22442198. Unknown parameter |month= ignored (help)
  7. Imazio, M.; Bobbio, M.; Cecchi, E.; Demarie, D.; Demichelis, B.; Pomari, F.; Moratti, M.; Gaschino, G.; Giammaria, M. (2005). "Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial". Circulation. 112 (13): 2012–6. doi:10.1161/CIRCULATIONAHA.105.542738. PMID 16186437. Unknown parameter |month= ignored (help)
  8. Colchicine for pericarditis: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Colchicine-for-Pericarditis/. Accessed November 16, 2014.
  9. 9.0 9.1 Imazio, M.; Brucato, A.; Cemin, R.; Ferrua, S.; Maggiolini, S.; Beqaraj, F.; Demarie, D.; Forno, D.; Ferro, S. (2013). "A Randomized Trial of Colchicine for Acute Pericarditis". N Engl J Med. doi:10.1056/NEJMoa1208536. PMID 23992557. Unknown parameter |month= ignored (help)
  10. Parikh, SV.; Memon, N.; Echols, M.; Shah, J.; McGuire, DK.; Keeley, EC. (2009). "Purulent pericarditis: report of 2 cases and review of the literature". Medicine (Baltimore). 88 (1): 52–65. doi:10.1097/MD.0b013e318194432b. PMID 19352300. Unknown parameter |month= ignored (help)
  11. Wheat, LJ.; Freifeld, AG.; Kleiman, MB.; Baddley, JW.; McKinsey, DS.; Loyd, JE.; Kauffman, CA. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045. Unknown parameter |month= ignored (help)
  12. Adler Y, Zandman-Goddard G, Ravid M, Avidan B, Zemer D, Ehrenfeld M, Shemesh J, Tomer Y, Shoenfeld Y (1994). "Usefulness of colchicine in preventing recurrences of pericarditis". Am J of Cardiol. 73 (12): 916–7. doi:10.1016/0002-9149(94)90828-1. PMID 8184826.
  13. Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial". Circulation. 112 (13): 2012–6. doi:10.1161/CIRCULATIONAHA.105.542738. PMID 16186437.
  14. Imazio M, Bobbio M, Cecchi E, Demarie D, Pomari F, Moratti M, Ghisio A, Belli R, Trinchero R (2005). "Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial". Arch Intern Med. 165 (17): 1987–91. doi:10.1001/archinte.165.17.1987. PMID 16186468.
  15. 15.0 15.1 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.

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