Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

  • Facebook Social Icon
  • Twitter Social Icon
  • Instagram Social Icon

Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

A Brief Approach to Pericarditis

August 6, 2019

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?

  1. Post MI pericarditis give aspirin and colchicine b/c any other NSAIDs inhibits scar formation

  2. 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

 

Share on Facebook
Share on Twitter
Please reload

Follow Us
  • Facebook Basic Square
  • Twitter Basic Square
  • Instagram Social Icon
Recent Posts

September 2, 2019

Please reload

Archive
Please reload

Search By Tags