Pericarditis: Diagnosis and Treatment

                                      Chris Bond, MD

Imazio M, et al. New Engl J Med 2013. PMID:23992557; Imazio M, et al. Arch Intern Med 2005. PMID:16186468; Imazio M, et al. Circ 2007. PMID:17502574

 

Diagnosis – 2 of 4 criteria required

1. Classic chest pain history – Sharp, pleuritic, and positional (improved by sitting up and leaning forward), radiating to trapezius ridge

2. Pericardial friction rub

3. Pericardial effusion on echocardiogram or ED bedside ultrasound

4. Characteristic ECG changes

 

3-Part Treatment

1. NSAID or Aspirin (ASA)

   Taper dose over 3-4 weeks

   No definite correct medication or dosing regimen has been established.

I use ibuprofen as follows:

                  600 mg po tid x 10 days, then

                  400 mg po tid x 10 days, then

                  200 mg po tid x 10 days

For ASA, Imazios study used 800 mg tid for 7-10 days, followed by taper over 3-4 weeks. Suggestion is 2-4 g of ASA per day, and will vary based on tablet size in each country.For Canada (325 mg tabs) a possible regimen is:

                  975 mg po tid x 10 days, then

                  650 mg po tid x 10 days, then

                  325 mg po tid x 10 days

2. Colchicine 

   If >70 kg, 0.6 mg po BID x 3 months   

   If <70 kg, 0.6 mg po daily x 3 months

   If diarrhea intractable, decrease dose to once daily for >70 kg or stop for <70 kg

   Note: Some countries have 0.5 mg tabs only (Canada is 0.6 mg)

3. Proton pump inhibitor (PPI) once daily x 3 months

 

Note: Steroids should be avoided in all cases except refractory cases and neoplastic/autoimmune causes.  Steroids are an independent risk for increased recurrence of pericarditis.  Expert consultation strongly recommended if prescribing.

 

Cost of Colchicine per Pill

   Canada/ Europe: ~$0.50-1                   USA: Up to $5 per pill

 

Contraindications to Colchicine

   Tuberculous, purulent or neoplastic pericarditis

   Severe liver disease or aminotransferase levels 1.5x upper limits of normal

   Serum creatinine >2.5 mg/dL (>221 umol/L)

   Skeletal myopathy or CK > upper limits of normal

   Blood dyscrasia

   Inflammatory bowel disease

   Life expectancy 18 months

   Pregnancy or lactation

   Women of childbearing potential not using contraception

   Hypersensitivity to colchicine or other contraindication to its use

 

Predictors of poor outcome – Recurrence, tamponade, and constriction

Predictor

Hazard Ratio

95% confidence interval

Female gender

1.67

1.03 to 2.70

Fever >38C

3.56

1.82 to 6.95

Subacute course

3.97

1.66 to 9.50

Large effusion (>2 cm) or tamponade

2.15

1.09 to 4.23

ASA or NSAID failure

2.50

1.28 to 4.91