Acute%20pericarditis Treatment

• Treatment goals are to relieve pain, resolve inflammation and prevent recurrence
• Specific therapy tailored to the identified etiology or underlying disorder is indicated
• Choice of therapeutic agent is based on patient’s medical history (prior efficacy or side effects, contraindications), concomitant diseases (preferring Aspirin when it is already used as antiplatelet therapy) and physician’s knowledge and skills
• Physical activity restriction is recommended for all patients until resolution of symptoms and normalization of CRP, ECG and echocardiogram [at least 3 months for athletes, shorter period (until remission) for non-athletes]

Aspirin and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• First-line agents for acute pericarditis
• Aspirin is the preferred agent for patients with pericarditis following myocardial infarction or any history of coronary disease 
• Commonly used NSAIDs include Ibuprofen and Indomethacin
• Given for 1-2 weeks then tapered once symptoms resolve and serum inflammatory markers improve (consider serum CRP levels in guiding duration of treatment and evaluating efficacy of therapy)
  • 2-4 weeks for recurrent pericarditis
• Gastroprotection should be considered due to the high doses required
• Suspect a cause other than postviral or idiopathic if symptoms (eg fever or chest discomfort) persist >1 week or a larger or new pericardial effusion develops during treatment
• Use is off-label

Colchicine

• Used as an adjunct to Aspirin and NSAID therapy
• Reduces persistence of symptoms at 72 hours, increases remission rate at 7 days and helps reduce recurrence rate in half
• Duration of therapy is up to 3 months
  • Up to 6 months for recurrent pericarditis
• Well tolerated when given long-term at a low dose
  • Uncommon side effects include hepatic toxicity and myelosuppression
• Reduce dose in patients with moderate renal dysfunction; avoid concurrent therapy with P-glycoprotein inhibitors or strong CYP3A4 inhibitors in patients with renal or hepatic impairment
• Generally effective for post-cardiac injury syndromes and systemic inflammatory pericarditis but not in cases of malignancy-related or bacterial pericarditis

Glucocorticoids

• Given to patients who are intolerant of, refractory to, or have contraindications to Aspirin or NSAIDs and Colchicine
  • Also considered when a specific indication, eg autoimmune disease, is present or an infectious etiology has been excluded
• Not used as primary therapy in patients with acute pericarditis due to high rate of relapse
• Given at a low dose for 2 weeks then tapered slowly; 2-4 weeks for recurrent pericarditis
  • In the setting of incomplete response to Aspirin or NSAIDs and Colchicine in patients with recurrent pericarditis, triple therapy with low- to moderate-dose steroids added to Aspirin or NSAIDs and Colchicine is given (not to be used as a substitute for these drugs) then tapered with a single drug class at a time before Colchicine is slowly discontinued, ie Colchicine is the last drug to be stopped
  • Slow tapering and a prolonged course of steroid therapy may be required though with potential for steroid-associated side effects and risk of additional recurrences; consider measures for osteoporosis prevention

Other Agents

• For patients who failed treatment with 2nd-line agents (eg Aspirin or NSAIDs with Colchicine plus steroid) or those with refractory recurrent pericarditis, other promising therapeutic agents to consider include Azathioprine, intravenous immunoglobulins (IVIG), interleukin-1 (IL-1) antagonist (Anakinra), immunosuppressive drugs [Methotrexate, anti-tumor necrosis factor (TNF) agent, Cyclosporine, Cyclophosphamide, Hydroxychloroquine]
  • In patients with documented corticosteroid-dependent, infection-negative recurrent pericarditis unresponsive to Colchicine, consider giving Azathioprine, IVIG and Anakinra
    • Advantages of treatment with Anakinra (eg rapid onset of treatment effects and quick steroid withdrawal) were seen in the randomized controlled Anakinra-Treatment of Recurrent Idiopathic Pericarditis (AIRTRIP) trial
  • Methotrexate and Mycophenolate mofetil may be considered in patients with idiopathic recurrent pericarditis unresponsive or with contraindications to corticosteroids

Pericardiectomy

• May be performed in patients with refractory recurrent pericarditis or constrictive pericarditis only when a trial of medical therapy had been unsuccessful  
  • May also be done in patients with a prior history of cardiac surgery, cardiac tamponade resulting from repeated pericardial effusion recurrences or steroid toxicity limiting additional medical therapy  
• Results can vary from complete remission to continuing symptoms; complete pericardial resection gives the best outcome  

Pericardial Window

• Allows drainage of pericardial fluid into the pleural space to prevent tamponade  
• Considered in patients when catheter drainage persists for >3-4 days  

Interventional Techniques

Pericardiocentesis

• Echocardiography- or fluoroscopy-guided
• Surgery is the gold standard approach for pericardial drainage and biopsy

Pericardioscopy

• Visualizes the pericardial sac and enables targeted biopsy