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Pericarditis
 

Pericarditis

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    Pericarditis Pericarditis Presentation Transcript

    • A Frustrating Disease in CardiologyCases and Treatment Options
    • 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
    • Does she have recurrent pericarditis? How would you treat her?
    • 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.
    • ECG
    • How would you treat him ?
    • 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
    • How would you treat him ?
    • Recurrent Pericarditis Objectives How to make the diagnosis? How is at risk? Prognosis Treatment options Guideline
    • 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
    • Etiology Heart 2004;90;1364-1368
    • 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 .
    • 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
    • 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.
    • Symptoms The most frequent symptom of recurrent pericarditis is chest pain. Typically sharp improve with sitting Mimic angina (exertional) once chronic .
    • 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
    • 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
    • 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
    • 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
    • What predicts recurrence ?
    • 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.
    • 1) Failure of NSAID 254 patients , 5 years f/u J Am Coll Cardiol 2004 Mar 17;43(6):1042-6.
    • 2) Steroid therapy 294 patients , 5 years f/u Am J Cardiol 2005 Sep 1;96(5):736-9.
    • Steroid therapy120 patients , 4 years f/u Circulation 2005 Sep 27;112(13):2012-6.
    • Therapy
    • 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.
    • 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
    • What is recommended…
    • Colchicine plus NSAID
    • COPE Circulation 2005 Sep 27;112(13):2012-6.
    • 48 patients, 4 years f/u CORE Am J Cardiol. 2005 Sep 1;96(5):736-9
    • 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
    • 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.
    • 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
    • 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
    • High vs. low steroid dose and duration 12 patients J Am Coll Cardiol 2005 Nov 1;26(5):1276-9.
    • 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.
    •  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
    • Immunosuppressant The ESC guidelines recommend azathioprine (75 to 100 mg/day). Methotrexate Cyclophosphamide IG
    • Intrapericardial therapy 260 patients15 patients Eur Heart J 2002 Oct;23(19):1503-8
    • Pericardiectomy Still a treatment option for refractory casesor its complication Constriction Operators dependent with high mortality rate .
    • Recurrent pain without objective evidence of disease 
    •  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.
    • 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
    • Does she have recurrent pericarditis? How would you treat her?
    •  NO Reassurance Tylenol and NSAID as needed Pain service Follow up with GP keeping in mind referral to cardiology for more objective findings .
    • 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.
    • How would you treat him ?
    •  Ibuprfen despite ASA failure and colchicine course for 3-6/12. Follow up
    • ECG 3 weeks
    • 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
    • How would you treat him ? What predicts recurrence ?
    •  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 .
    • Thanks