Pericarditis is an inflammation of the parietal or visceral layers of the heart. It has many causes, can mimic many conditions, and requires early diagnosis for prompt treatment in order to avoid long term sequelae.
How does it present?
Sharp/pleuritic chest pain
Radiates to back or shoulders
Better leaning forward and worse when lying flat
Associated with fever, chills, malaise
What will you find on exam?
Nothing
Pericardial friction rub
Pericardial effusion (large effusion think uremic pericarditis, systemic diseases, aortic dissection)
What are the criteria for diagnosis?
You need 2/4…AKA 2/3
Classic chest pain story for pericarditis
Friction rub
Effusion on echo
EKG changes
Stage 1: Diffuse ST elevations WITHOUT reciprocal changes- concave up. PR depressions
** Occurs over hours to days
Stage 2: Resolution of ST elevations and PR intervals and sometimes T waves inver
Stage 3: Normalization of ST and PR changes, and T wave inversion may persist
** REALIZE THIS LOOKS LIKE MI WHICH IS THE CANNOT MISS DIAGNOSIS
What can cause it?
Infectious: Viral, Bacterial (TB), Fungal, Parasitic,
Toxic: Medications, Uremia
Systemic Diseases: SLE, RA, Sarcoidosis, Amyloidosis, Dermatomyositis, Cancer (Lung, Breast, Lymphoma, Leukemia)
Injury: MI, Trauma, Radiation, Surgery
Other: Aortic Dissection
Idiopathic
Who should be admitted?
High risk criteria:
Fever > 38
Subacute course or rapid onset in pain
Hemodynamic instability
Tamponade
Large effusion
Immunosuppressed
On anticoagulation
Trauma
Positive troponins
*No response to outpatient management (1-2 weeks)
What is the best outpatient treatment regimen?
If you think it’s viral or idiopathic (majority of cases), NSAIDs and Colchicine together and remember GI prophylaxis:
NSAIDs:
Ibuprofen 600-800 TID until symptoms improved for 24 hours then taper weekly for 2-4 weeks to prevent recurrence
Aspirin 600-1000mg q6-q8 (same taper)
Indomethacin 25-50mg TID (same taper)
** Higher side effects, generally reserved for recurrent disease
Colchicine:
Should be added to NSAIDs. Multiple trials show that it decreases recurrence, decreases hospitalizations, and decreases the severity of symptoms. No serious adverse events.
Dosing:
>70kg: 0.6mg BID for 3 months
<70kg: 0.6mg once daily for 3 months
** Do not need to give a loading dose
Fun Fact: 0.6mg pills available in US and Canada and 0.5mg pills in other countries
GI prophylaxis: Omeprazole or pantoprazole once daily
What about ‘Roids?!
Steroids are associated with higher rate of recurrence
Reserved for people with contraindications to NSAIDs
Or for people with systemic inflammatory processes, pregnancy, renal failure
Dose: 0.2 - 0.5mg/kg/day for 2 weeks and then tapering over 3 months
Taper by ~20% of initial dose/day each 1-2 weeks
e.g. If 50mg/day then decrease by 10mg/day each 1-2 weeks
Are there any special considerations/ exceptions to the standard regimen?
Post MI pericarditis give aspirin and colchicine b/c any other NSAIDs inhibits scar formation
NSAIDs and aspirin alter vitamin K antagonist metabolism (which is why we admit these patients)
Won’t aspirin or NSAIDs increase risk of bleeding into pericardial space causing hemorrhagic pericardial tamponade?
453 consecutive cases says it won’t
What’s your point?
Don’t forget your troponins
Remember to do a bedside echo
Rule out MI before settling on pericarditis and scrutinize the EKG
Know who to admit and who you can send home
NSAIDs + colchicine and remember PPI - Treatment requires long course
Only specific cases need ‘Roids
Arman Sobhani, MD is a current third year resident at Stony Brook Emergency Medicine.
References
Edited by Bassam Zahid, MD