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, Imazio�s 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 >38�C

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