Pericarditis

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Pericarditis

  1. 1. A Frustrating Disease in CardiologyCases and Treatment Options
  2. 2. Case 1 53 y F with 3/12 CP typical to pericarditis attack 6/12 ago that was treated with ASA only for 14 days with complete recovery. Normal physical exam no rub Normal WBC and ESR Normal ECG ECHO: no PE
  3. 3. Does she have recurrent pericarditis? How would you treat her?
  4. 4. Case 2 48 y M with with 1 attack of pericarditis 4/12(treated with ASA with no good response ) ,came with SOB and extensional CP similar to his previous attack. V/S stable no rub ECHO : 0.7 cm effusion WBC 14 , CK and trop –ve.
  5. 5. ECG
  6. 6. How would you treat him ?
  7. 7. Case 3 68 y M with RA. Referred by GP with CP (pericarditis). Required multible steroid courses for RA. On going similar pain for 6/12 treated by his rheumatologist with steroid( 40 mg for 14 days). v/s stable no rub ECG non specific T changes ESR 82. ECHO : diastolic dysfunction with 1 cm PE with no increase in ICP
  8. 8. How would you treat him ?
  9. 9. Recurrent Pericarditis Objectives How to make the diagnosis? How is at risk? Prognosis Treatment options Guideline
  10. 10. Definition Need 1 + 2 + any of 31) A documented first attack of acute pericarditis2) Recurrent pain3) Fever Friction rub ECG changes Pericardial effusion Elevation WBC or ESR or CRP
  11. 11. Etiology Heart 2004;90;1364-1368
  12. 12. Causes of recurrence … (i) insufficient dose or treatment duration of the previous attack. (ii) early corticosteroid treatment causing augmented viral DNA/RNA replication in the pericardial tissue leading to increased viral antigen exposure. (iii) exacerbation of an underlying connective tissue disease .
  13. 13. Work up … Often negative Not recommended to consider routine pericardial tap for diagnostic purpose Work up for infectious and or CT 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
  14. 14. Course and types The first symptoms of recurrent pericarditis occur at a variable time after the initial attack, but usually within 18 to 20 months.1)The intermittent form, symptoms start after a symptom- free interval longer than six weeks after drug withdrawal .2)The incessant form, symptoms appear within six weeks after drug discontinuation or during attempted weaning.
  15. 15. Symptoms The most frequent symptom of recurrent pericarditis is chest pain. Typically sharp improve with sitting Mimic angina (exertional) once chronic .
  16. 16. Answer this .. ………. is the most common cause of SOB in patients with recurrent pericarditis . A) Tamponade B) Constrictive pericarditis C) All of above D) Non of the above Answer is D
  17. 17. Complications 31 patients , follow up for 2-19y : 3 patients had Tamponade initially None during recurrence No constriction J Am Coll Cardiol 1986 Feb;7(2):300-5
  18. 18. Complications 221 patients , 5 years f/u 15 patients , 8 years f/uJ Am Coll Cardiol. 2003 Aug 20;42(4):759-64. JACC Vol. 43, No. 6, 2004 March 17, 2004:1042–6
  19. 19. Prognosis Prognosis is excellent for most patients with idiopathic recurrent pericarditis. Severe complications are uncommon even with multiple recurrences Not associated with myocardial systolic or diastolic dysfunction Rarely associated with constriction . Quality 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
  20. 20. What predicts recurrence ?
  21. 21. Predictors of recurrence  No presenting clinical feature of an initial episode of acute pericarditis reliably predicts recurrence. The response to therapy and type of therapy for the initial episode may have some prognostic value.
  22. 22. 1) Failure of NSAID 254 patients , 5 years f/u J Am Coll Cardiol 2004 Mar 17;43(6):1042-6.
  23. 23. 2) Steroid therapy 294 patients , 5 years f/u Am J Cardiol 2005 Sep 1;96(5):736-9.
  24. 24. Steroid therapy120 patients , 4 years f/u Circulation 2005 Sep 27;112(13):2012-6.
  25. 25. Therapy
  26. 26. Before that… Recurrent pericarditis can be a prolonged and frustrating disease to patients and doctors. Because of this and the need to maintain compliance, effective communication with the patient is important.
  27. 27. Things to keep in mind… Further recurrences are possible Not always the same etiology Good prognosis The possibility of pericardiectomy Complications of immunosuppressant Out patient therapy
  28. 28. What is recommended…
  29. 29. Colchicine plus NSAID
  30. 30. COPE Circulation 2005 Sep 27;112(13):2012-6.
  31. 31. 48 patients, 4 years f/u CORE Am J Cardiol. 2005 Sep 1;96(5):736-9
  32. 32. Recommended dose for Colchicine > 70 kg 2 mg/day for 1-2 days, followed dose of 1 mg/day for 6/12 plus NSAID and at least for 3/12. < 70 kg 1 mg/day for 1-2 days followed by 0.5 mg/daily for 6/12 plus NSAID at least for 3/12. Bone marrow suppression, hepatotoxicity, muscle and kidney toxicity
  33. 33. NSAID The patients prior experience can provide a useful guide. If a patient reports that a specific NSAID drug has proven effective, it is reasonable to use that agent. This approach should be maintained until it is clear that NSAIDs have failed to control the syndrome, especially the pain, or that the drugs are not tolerated.
  34. 34. Recommended NSAID Ibuprofen 800 mg four times daily then 600 mg four times daily at two weeks and to 400 mg four times daily at four weeks. ASA 2.0 to 4.0 g/day in divided doses for patients with CAD. Treatment is discontinued after 3/12. Slow tapering is recommended in an attempt to reduce the subsequent recurrence rate. Prophylactic PPI
  35. 35. Steroids are not bad…but Glucocorticoid therapy should generally be avoided in patients with recurrent pericarditis May be required to treat patients who fail NSAID and/or colchicine therapy. Common mistakes are to use too low dose and, more often, to taper the dose too rapidly
  36. 36. High vs. low steroid dose and duration 12 patients J Am Coll Cardiol 2005 Nov 1;26(5):1276-9.
  37. 37. Tapering the dose Prednisone 1-1.5/kg/day is the ideal . Tapered 10 mg/day every one to two weeks for total of 3/12 Each decrement in steroid dose should proceed only if the patient is asymptomatic and C- reactive protein is normal.
  38. 38.  Toward the end of the taper, NSAID or colchicine should be introduced to complete 3- 6/12 if needed. If symptoms recur every effort should be made not to increase or reinstitute corticosteroids, but instead control symptoms with NSAID. Osteoporosis prevention
  39. 39. Immunosuppressant The ESC guidelines recommend azathioprine (75 to 100 mg/day). Methotrexate Cyclophosphamide IG
  40. 40. Intrapericardial therapy 260 patients15 patients Eur Heart J 2002 Oct;23(19):1503-8
  41. 41. Pericardiectomy Still a treatment option for refractory casesor its complication Constriction Operators dependent with high mortality rate .
  42. 42. Recurrent pain without objective evidence of disease 
  43. 43.  A difficult management . This problem is most likely to occur in more chronic cases in which numerous recurrences have been suppressed by steroid. Pain management should be initiated Pain management begins with Tylenol Pain service Watch for recurrence.
  44. 44. Case 1 53 y F with 3/12 CP typical to pericarditis attack 6/12 ago that was treated with ASA only for 14 days with complete recovery. Normal physical exam no rub Normal WBC and ESR Normal ECG ECHO: no PE
  45. 45. Does she have recurrent pericarditis? How would you treat her?
  46. 46.  NO Reassurance Tylenol and NSAID as needed Pain service Follow up with GP keeping in mind referral to cardiology for more objective findings .
  47. 47. Case 2 48 y M with with 1 attack of pericarditis 4/12(treated with ASA with no good response ) ,came with SOB and extensional CP similar to his previous attack. V/S stable no rub ECHO : 0.7 cm effusion WBC 14 , CK and trop –ve.
  48. 48. How would you treat him ?
  49. 49.  Ibuprfen despite ASA failure and colchicine course for 3-6/12. Follow up
  50. 50. ECG 3 weeks
  51. 51. Case 3 68 y M with RA. Referred by GP with CP (pericarditis). Required multible steroid courses for RA. On going similar pain for 6/12 treated by his rheumatologist with steroid( 40 mg for 14 days). v/s stable no rub ECG non specific T changes ESR 82. ECHO : diastolic dysfunction with 1 cm PE with no increase in ICP
  52. 52. How would you treat him ? What predicts recurrence ?
  53. 53.  NSAID and colchicine for 3-6/12 No steroid after talking to rheumatologist . After 1/12 pain got wore despite ASA and colchicine . Switched to prednisone 70mg/day tapered slowly over 3/12 .
  54. 54. Thanks

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