Pericarditis treatment


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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 in the Absence of Significant Pericardial Effusion and Tamponade
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 effect 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. 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 considered.

Aspirin Therapy
An alternative therapy is aspirin 800 mg every 6-8 hours.

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.

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:
 * Acute onset
 * High fever (> 100.4 F) and leukocytosis
 * Development of cardiac tamponade
 * Large pericardial effusion (echo-free space > 20 mm) resistant to NSAID treatment
 * Immunocompromised status
 * History of oral anticoagulation therapy
 * Pericarditis secondary to acute trauma
 * Failure to respond to seven days of NSAID treatment

The Management of Complicated Pericarditis Including Patients with Cardiac Tamponade and Large Pericardial Effusions
See also: Cardiac tamponade, Pericardial effusions, Constrictive pericarditis, Pericardiocentesis


 * Pericardiocentesis may be required to relieve a large effusion or treat cardiac tamponade
 * Antibiotics may be required to manage an underlying infection or to manage purulent pericarditis
 * Steroids may be required in recurrent refractory cases or in patients with autoimmune disease
 * Colchicine may be required in patients with recurrent or refractory disease (see below)
 * Surgery in the presence of recurrent effusion or constrictive pericarditis

Management of Cardiac Tamponade and Large Pericardial Effusions
Pericardiocentesis is an invasive procedure in which the fluid in a pericardial effusion is drained through a needle. A pericardial window is a surgical procedure to drain fluid form the pericardium. Indications for pericardiocenteis or a pericardial window include the following:
 * Cardiac tamponade
 * For diagnostic purposes if there is suspected purulent, tuberculosis, or neoplastic pericarditis
 * The presence of a large, persistent, symptomatic pericardial effusion

Management of Recurrent Pericarditis
Colchicine can be used alone or in conjunction with NSAIDs in prevention of recurrent pericarditis and treatment of recurrent pericarditis. Treatment involves a NSAID plus colchicine 2 mg on first day followed by 1 mg daily for three months.

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.