Medical Care: Initially, medical care is focused on determination of the underlying etiology.
" Aspirin/nonsteroidal anti-inflammatory agents (NSAIDs)
o Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with aspirin (650 mg q6h) or another NSAID.
o Aspirin may be the preferred nonsteroidal agent to treat pericarditis after myocardial infarction because other NSAIDs may interfere with myocardial healing.
o Indomethacin should be avoided in patients who may have coronary artery disease.
" Colchicine: The routine use of colchicine is supported by recently reported results of the COlchicine for acute PEricarditis (COPE) trial. In this trial, 120 patients with a first episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, and connective tissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg/d for 3 mo). Colchicine reduced symptoms at 72 hours (11.7% vs 36.7%; P=0.03) and reduced recurrence at 18 months (10.7% vs 36.7%; P=0.004; 5 needed treatment). Colchicine was discontinued in 5 patients because of diarrhea. No other adverse events were noted. Importantly, none of the 120 patients developed cardiac tamponade or progressed to pericardial constriction.
" Steroids
o Steroid administration early in the course of acute pericarditis appears to be associated with an increased incidence of relapse after tapering the steroids.
o In the COPE trial, steroid use was an independent risk factor for recurrence (odds ratio=4.3). Also, an observational study strongly suggests that the use of steroids increases the probability of relapse in patients treated with colchicine.
o Systemic steroids should be considered only in patients with recurrent pericarditis unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone) should be given, and it should be continued for at least 1 month before slow tapering.
o The intrapericardial administration of steroids has been reported to be effective in acute pericarditis without producing the frequent reoccurrence of pericarditis that complicates the use of systemic steroids, but the invasive nature of this procedure limits its use.
" Hemodynamic support
o Patients who have effusions with actual or threatened tamponade should be considered to have a true or potential emergency. Most patients require pericardiocentesis to treat or prevent tamponade. However, treatment should be carefully individualized.
o Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially in those with threatened or mild tamponade in whom a decision is made to defer pericardiocentesis. Hemodynamic monitoring is also helpful after pericardiocentesis to assess both reaccumulation and the presence of underlying constrictive disease. However, insertion of a pulmonary artery catheter should not be allowed to delay definitive therapy in critically ill patients.
o Intravenous fluid resuscitation may be helpful in cases of hemodynamic compromise.
o In patients with tamponade who are critically ill, intravenous positive inotropes (dobutamine, dopamine) can be used but are of limited measures and should not be allowed to substitute for or delay pericardiocentesis.
" Antibiotics
o In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg/d) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable.
o The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day. Prednisone 1-2 mg/kg/day is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks. Drug sensitivity testing is essential. Uncertainty remains whether adjunctive corticosteroids are effective in reducing mortality or progression to constriction. Surgical resection of the pericardium remains the appropriate treatment for constrictive pericarditis. The timing of surgical intervention is controversial, but many experts recommend a trial of medical therapy for noncalcific pericardial constriction and pericardiectomy in nonresponders after 4-8 weeks of antituberculosis chemotherapy.
" Antineoplastic therapy (eg, systemic chemotherapy, radiation) in conjunction with pericardiocentesis has been shown to be effective in reducing recurrences of malignant effusions.
" Corticosteroids and NSAIDs are helpful in patients with autoimmune conditions.
Surgical Care:
" Subxiphoid pericardial window with pericardiostomy
o This procedure is associated with low morbidity, mortality, and recurrence rates.
o It can be performed under local anesthesia.
o It may be less effective when effusion is loculated.
o It may replace pericardiocentesis as initial treatment for stable pericardial effusions.
o A recent study suggests that this may be safer and more effective at reducing recurrence rates than pericardiocentesis. However, only patients who were hemodynamically unstable underwent pericardiocentesis, and no change in overall survival rate was observed.
" Thoracotomy
o This should be reserved for patients in whom conservative approaches have failed.
o Thoracotomy allows for creation of a pleuropericardial window, which provides greater visualization of pericardium.
o Thoracotomy requires general anesthesia and thus has higher morbidity and mortality rates than the subxiphoid approach.
" Video-assisted thoracic surgery
o Video-assisted thoracic surgery (VATS) enables resection of a wider area of pericardium than the subxiphoid approach without the morbidity of thoracotomy.
o The surgeon is able to create a pleuropericardial window and address concomitant pleural pathology, which is especially common in patients with malignant effusions.
o One disadvantage of VATS is that it requires general anesthesia with single lung ventilation, which may be difficult in otherwise seriously ill patients.
" Median sternotomy
o This procedure is reserved for patients with constrictive pericarditis.
o Operative mortality rate is high (5-15%).
DRUG TREATMENT : AUTOIMMUNE PERICARDIAL EFFUSION RESPONDS TO TREATMENT WITH NSAIDS ONLY.
- INDOMETHACIN - DRUG OF CHOICE
- IBUPROFEN
- NAPROXIN
- ASPIRIN
2. CORTICOSTEROIDS :
- PREDNISONE
- METHYLPREDNISOLONE