Pericarditis

A Frustrating Disease in A Frustrating Disease in Cardiology Cardiology

Cases and Treatment Cases and Treatment Options Options

Case 1Case 1

53 y F with 3/12 CP typical to 53 y F with 3/12 CP typical to pericarditis attack 6/12 ago that was pericarditis attack 6/12 ago that was treated with ASA only for 14 days treated with ASA only for 14 days with complete recovery.with complete recovery.

Normal physical exam no rubNormal physical exam no rub Normal WBC and ESRNormal WBC and ESR Normal ECGNormal ECG ECHO: no PEECHO: no PE

Does she have Does she have recurrent pericarditis?recurrent pericarditis?

How would you treat her?How would you treat her?

Case 2Case 2

48 y M with with 1 attack of 48 y M with with 1 attack of pericarditis 4/12(treated with ASA pericarditis 4/12(treated with ASA with no good response ) ,came with with no good response ) ,came with SOB and extensional CP similar to SOB and extensional CP similar to his previous attack.his previous attack.

V/S stable no rub V/S stable no rub ECHO : 0.7 cm effusion ECHO : 0.7 cm effusion WBC 14 , CK and trop –ve.WBC 14 , CK and trop –ve.

ECGECG

How would you treat How would you treat him ?him ?

Case 3Case 3 68 y M with RA. Referred by GP with CP 68 y M with RA. Referred by GP with CP

(pericarditis).(pericarditis). Required multible steroid courses for RA.Required multible steroid courses for RA. On going similar pain for 6/12 treated by On going similar pain for 6/12 treated by

his rheumatologist with steroid( 40 mg for his rheumatologist with steroid( 40 mg for 14 days).14 days).

v/s stable no rubv/s stable no rub ECG non specific T changes ECG non specific T changes ESR 82. ESR 82. ECHO : diastolic dysfunction with 1 cm PE ECHO : diastolic dysfunction with 1 cm PE

with no increase in ICPwith no increase in ICP

How would you treat How would you treat him ?him ?

Objectives Objectives

How to make the diagnosis?How to make the diagnosis? How is at risk?How is at risk? Prognosis Prognosis Treatment optionsTreatment options Guideline Guideline

Recurrent PericarditisRecurrent Pericarditis

Definition Definition

Need 1 + 2 + any of 3Need 1 + 2 + any of 31) A documented first attack of acute 1) A documented first attack of acute

pericarditis pericarditis 2) Recurrent pain 2) Recurrent pain 3) 3) FeverFever Friction rubFriction rub ECG changesECG changes Pericardial effusion Pericardial effusion Elevation WBC or ESR or CRPElevation WBC or ESR or CRP

EtiologyEtiology

Heart 2004;90;1364-1368

Causes of recurrence …Causes of recurrence …

(i) insufficient dose or treatment (i) insufficient dose or treatment duration of the previous attack.duration of the previous attack.

(ii) early corticosteroid treatment (ii) early corticosteroid treatment causing augmented viral DNA/RNA causing augmented viral DNA/RNA replication in the pericardial tissue replication in the pericardial tissue leading to increased viral antigen leading to increased viral antigen exposure.exposure.

(iii) exacerbation of an underlying (iii) exacerbation of an underlying connective tissue disease .connective tissue disease .

Work up …Work up …

Often negative Often negative Not recommended to consider Not recommended to consider

routine pericardial tap for diagnostic routine pericardial tap for diagnostic purpose purpose

Work up for infectious and or CT Work up for infectious and or CT causes are guided by clinical picture causes are guided by clinical picture

Mayo Clin Proc 2002 Jan;77(1):39-43 Am J Cardiol. 2006 Jul 15;98(2):267-71 Am J Cardiol 2005 Sep 1;96(5):736-9

Course and types Course and types The first symptoms of recurrent pericarditis The first symptoms of recurrent pericarditis

occur at a variable time after the initial occur at a variable time after the initial attack, but usually within attack, but usually within 18 to 20 months18 to 20 months..

1)The intermittent form, symptoms start after 1)The intermittent form, symptoms start after a symptom-free interval a symptom-free interval longer than six longer than six weeksweeks after drug withdrawal . after drug withdrawal .

2)The incessant form, symptoms appear 2)The incessant form, symptoms appear within six weekswithin six weeks after drug discontinuation after drug discontinuation or during attempted weaning.or during attempted weaning.

Symptoms Symptoms

The most frequent symptom of The most frequent symptom of recurrent pericarditis is chest pain.recurrent pericarditis is chest pain.

Typically sharp improve with sitting Typically sharp improve with sitting Mimic angina (exertional) once Mimic angina (exertional) once

chronic .chronic .

Answer this .. Answer this .. ………………. is the most common cause of SOB . is the most common cause of SOB

in patients with recurrent pericarditis .in patients with recurrent pericarditis .

A) Tamponade A) Tamponade B) Constrictive pericarditis B) Constrictive pericarditis C) All of aboveC) All of above D) Non of the aboveD) Non of the above

Answer is D Answer is D

Complications Complications

31 patients , follow up for 2-19y :31 patients , follow up for 2-19y : 3 patients had Tamponade initially3 patients had Tamponade initially None during recurrence None during recurrence No constriction No constriction

J Am Coll Cardiol 1986 Feb;7(2):300-5

Complications Complications

J Am Coll Cardiol. 2003 Aug 20;42(4):759-64. JACC Vol. 43, No. 6, 2004 March 17, 2004:1042–6

15 patients , 8 years f/u

221 patients , 5 years f/u

PrognosisPrognosis Prognosis is excellent for most patients Prognosis is excellent for most patients

with with idiopathic recurrent pericarditisidiopathic recurrent pericarditis. . Severe complications are uncommon Severe complications are uncommon

even with multiple recurrences even with multiple recurrences Not associated with myocardial Not associated with myocardial

systolic or diastolic dysfunctionsystolic or diastolic dysfunction Rarely associated with constriction . Rarely associated with constriction . Quality of life can be severely affectedQuality of life can be severely affected

Mayo Clin Proc 2002 Jan;77(1):39-43

Am J Cardiol. 2006 Jul 15;98(2):267-71

Am J Cardiol 2005 Sep 1;96(5):736-9

What predicts What predicts recurrence ?recurrence ?

Predictors of recurrencePredictors of recurrence

  No presenting clinical feature of an No presenting clinical feature of an initial episode of acute pericarditis initial episode of acute pericarditis reliably predicts recurrence.reliably predicts recurrence.

The response to therapy and type of The response to therapy and type of therapy for the initial episode may therapy for the initial episode may have some prognostic value. have some prognostic value.

1) Failure of NSAID1) Failure of NSAID

J Am Coll Cardiol 2004 Mar 17;43(6):1042-6.

254 patients , 5 years f/u

2) Steroid therapy 2) Steroid therapy

Am J Cardiol 2005 Sep 1;96(5):736-9.

294 patients , 5 years f/u

Steroid therapySteroid therapy

Circulation 2005 Sep 27;112(13):2012-6.

120 patients , 4 years f/u

Therapy Therapy

Before that… Before that…

Recurrent pericarditis can be a Recurrent pericarditis can be a prolonged and frustrating disease to prolonged and frustrating disease to patients and doctorspatients and doctors..

Because of this and the need to Because of this and the need to maintain compliance, effective maintain compliance, effective communication with the patient is communication with the patient is important. important.

Things to keep in mind… Things to keep in mind…

Further recurrences are possibleFurther recurrences are possible Not always the same etiology Not always the same etiology Good prognosisGood prognosis The possibility of pericardiectomyThe possibility of pericardiectomy Complications of Complications of

immunosuppressantimmunosuppressant Out patient therapy Out patient therapy

What is recommended…What is recommended…

Colchicine Colchicine plus plus NSAIDNSAID

COPECOPE

Circulation 2005 Sep 27;112(13):2012-6.

CORECORE

Am J Cardiol. 2005 Sep 1;96(5):736-9

48 patients, 4 years f/u

Recommended dose for Recommended dose for Colchicine Colchicine

> 70 kg 2 mg/day for 1-2 days, > 70 kg 2 mg/day for 1-2 days, followed dose of 1 mg/day for 6/12 followed dose of 1 mg/day for 6/12 plus NSAID and at least for 3/12. plus NSAID and at least for 3/12.

< 70 kg 1 mg/day for 1-2 days < 70 kg 1 mg/day for 1-2 days followed by 0.5 mg/daily for 6/12 followed by 0.5 mg/daily for 6/12 plus NSAID at least for 3/12. plus NSAID at least for 3/12.

Bone marrow suppression, Bone marrow suppression, hepatotoxicity, muscle and kidney hepatotoxicity, muscle and kidney toxicitytoxicity

NSAID NSAID

The patient's The patient's prior experienceprior experience can can provide a useful guide. provide a useful guide.

If a patient reports that a specific If a patient reports that a specific NSAID drug has proven effective, it NSAID drug has proven effective, it is reasonable to use that agent. is reasonable to use that agent.

This approach should be maintained This approach should be maintained until it is clear that NSAIDs have until it is clear that NSAIDs have failed to control the syndrome, failed to control the syndrome, especially the pain, or that the drugs especially the pain, or that the drugs are not tolerated.are not tolerated.

Recommended NSAID Recommended NSAID Ibuprofen 800 mg four times daily then Ibuprofen 800 mg four times daily then

600 mg four times daily at two weeks and 600 mg four times daily at two weeks and to 400 mg four times daily at four weeks. to 400 mg four times daily at four weeks.

ASA 2.0 to 4.0 g/day in divided doses for ASA 2.0 to 4.0 g/day in divided doses for patients with CAD.patients with CAD.

Treatment is discontinued after 3/12. Treatment is discontinued after 3/12. Slow tapering is recommended in an Slow tapering is recommended in an attempt to reduce the subsequent attempt to reduce the subsequent recurrence rate.recurrence rate.

Prophylactic PPI Prophylactic PPI

Steroids are not bad…but Steroids are not bad…but

Glucocorticoid therapy should generally be Glucocorticoid therapy should generally be avoidedavoided in patients with recurrent in patients with recurrent pericarditispericarditis

May be required to treat patients who May be required to treat patients who fail fail

NSAID and/or colchicine therapy.NSAID and/or colchicine therapy.

Common mistakes are to use too low dose Common mistakes are to use too low dose and, more often, to taper the dose too and, more often, to taper the dose too rapidlyrapidly

High vs. low steroid doseHigh vs. low steroid doseand duration and duration

J Am Coll Cardiol 2005 Nov 1;26(5):1276-9.

12 patients

Tapering the dose Tapering the dose

Prednisone 1-1.5/kg/day is the ideal .Prednisone 1-1.5/kg/day is the ideal .

Tapered 10 mg/day every one to two Tapered 10 mg/day every one to two weeksweeksfor total of 3/12for total of 3/12

Each decrement in steroid dose should Each decrement in steroid dose should proceed only if the patient is asymptomatic proceed only if the patient is asymptomatic and C-reactive protein is normal.and C-reactive protein is normal.

Toward the end of the taper, NSAID or Toward the end of the taper, NSAID or colchicine should be introduced to colchicine should be introduced to complete 3-6/12 if needed.complete 3-6/12 if needed.

If symptoms recur every effort should If symptoms recur every effort should be made not to increase or reinstitute be made not to increase or reinstitute corticosteroids, but instead control corticosteroids, but instead control symptoms with NSAID. symptoms with NSAID.

Osteoporosis preventionOsteoporosis prevention

Immunosuppressant Immunosuppressant

The ESC guidelines recommend The ESC guidelines recommend azathioprine (75 to 100 mg/day).azathioprine (75 to 100 mg/day).

MethotrexateMethotrexate CyclophosphamideCyclophosphamide IG IG

Intrapericardial therapyIntrapericardial therapy

Eur Heart J 2002 Oct;23(19):1503-8

15 patients

260 patients

Pericardiectomy Pericardiectomy

Still a treatment option for Still a treatment option for refractory cases refractory cases

or its complication Constriction or its complication Constriction Operators dependent with high Operators dependent with high

mortality rate .mortality rate .

Recurrent pain without Recurrent pain without objective evidence of objective evidence of

diseasedisease  

A difficult management .A difficult management . This problem is most likely to occur in This problem is most likely to occur in

more more chronic cases in which numerous chronic cases in which numerous recurrences have been suppressed by recurrences have been suppressed by steroid.steroid.

Pain management should be initiated Pain management should be initiated Pain management begins with Tylenol Pain management begins with Tylenol Pain servicePain service Watch for recurrence.Watch for recurrence.

Case 1Case 1

53 y F with 3/12 CP typical to 53 y F with 3/12 CP typical to pericarditis attack 6/12 ago that was pericarditis attack 6/12 ago that was treated with ASA only for 14 days treated with ASA only for 14 days with complete recovery.with complete recovery.

Normal physical exam no rubNormal physical exam no rub Normal WBC and ESRNormal WBC and ESR Normal ECGNormal ECG ECHO: no PEECHO: no PE

Does she have Does she have recurrent pericarditis?recurrent pericarditis?

How would you treat her?How would you treat her?

NONO ReassuranceReassurance Tylenol and NSAID as needed Tylenol and NSAID as needed Pain servicePain service Follow up with GP keeping in mind Follow up with GP keeping in mind

referral to cardiology for more referral to cardiology for more objective findings . objective findings .

Case 2Case 2

48 y M with with 1 attack of 48 y M with with 1 attack of pericarditis 4/12(treated with ASA pericarditis 4/12(treated with ASA with no good response ) ,came with with no good response ) ,came with SOB and extensional CP similar to SOB and extensional CP similar to his previous attack.his previous attack.

V/S stable no rub V/S stable no rub ECHO : 0.7 cm effusion ECHO : 0.7 cm effusion WBC 14 , CK and trop –ve.WBC 14 , CK and trop –ve.

How would you treat How would you treat him ?him ?

Ibuprfen despite ASA failure and Ibuprfen despite ASA failure and colchicine course for 3-6/12.colchicine course for 3-6/12.

Follow up Follow up

ECG 3 weeks ECG 3 weeks

Case 3Case 3 68 y M with RA. Referred by GP with CP 68 y M with RA. Referred by GP with CP

(pericarditis).(pericarditis). Required multible steroid courses for RA.Required multible steroid courses for RA. On going similar pain for 6/12 treated by On going similar pain for 6/12 treated by

his rheumatologist with steroid( 40 mg for his rheumatologist with steroid( 40 mg for 14 days).14 days).

v/s stable no rubv/s stable no rub ECG non specific T changes ECG non specific T changes ESR 82. ESR 82. ECHO : diastolic dysfunction with 1 cm PE ECHO : diastolic dysfunction with 1 cm PE

with no increase in ICPwith no increase in ICP

How would you treat How would you treat him ?him ?

What predicts recurrence ?What predicts recurrence ?

NSAID and colchicine for 3-6/12NSAID and colchicine for 3-6/12 No steroid after talking to No steroid after talking to

rheumatologist .rheumatologist . After 1/12 pain got wore despite ASA After 1/12 pain got wore despite ASA

and colchicine .and colchicine . Switched to prednisone 70mg/day Switched to prednisone 70mg/day

tapered slowly over 3/12 . tapered slowly over 3/12 .

Thanks Thanks