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 |