cardiovascular disorders
Pericarditis
Treatment of Pericarditis
Nonsteroidal anti-inflammatory drugs (NSAIDs),colchicine, and, infrequently, corticosteroids for pain and inflammation. Pericardiocentesis for tamponade and some large effusions Sometimes intrapericardial drugs (eg,triamcinolone) Sometimes pericardial resection for constrictive pericarditis, particularly when symptomatic Treatment of underlying cause (eg, cancer) ) are stopped. For cardiac tamponade, immediate pericardiocentesis (see figure Pericardiocentesis ) is done; removal of even a small volume of fluid may be lifesaving. Except in emergencies (eg, cardiac tamponade), pericardiocentesis, a potentially lethal procedure, should be done using echocardiographic guidance in a cardiac catheterization laboratory and should be supervised by a cardiologist or thoracic surgeon if possible. Resuscitation equipment must be at hand. IV sedation (eg,morphine0.1 mg/kg orfentanyl25 to 50 μg plusmidazolam3 to 5 mg) is desirable. The patient should be recumbent, with the head elevated 30°from the horizontal. Under aseptic conditions, the skin and subcutaneous tissues are infiltrated withlidocaine. A 75-mm short-beveled, 16-gauge needle is attached via a 3-way stopcock to a 30- or 50-mL syringe. The pericardium may be entered via the right or left xiphocostal angle or from the tip of the xiphoid process with the needle directed inward, upward, and close to the chest wall. The needle is advanced with constant suction applied to the syringe. Echocardiography may be used to guide the needle as agitated saline is injected through it. Echocardiography is also increasingly used to identify the optimal puncture site and the needle trajectory. Once in place, the needle should be clamped next to the skin to prevent it from entering further than necessary and possibly puncturing the heart or injuring a coronary vessel. ECG monitoring is essential for detecting arrhythmias produced when the myocardium is touched or punctured. As a rule, right atrial pressure and pulmonary artery occlusion pressure (pulmonary capillary wedge pressure) are monitored. Fluid is withdrawn until intrapericardial pressure falls below right atrial pressure, usually to subatmospheric levels. If continued drainage is needed, a plastic catheter may be passed through the needle into the pericardium and the needle withdrawn. The catheter may be left in place for 2 to 4 days. Pain can usually be controlled withcolchicineoraspirin325 to 650 mg orally every 4 to 6 hours or other NSAIDs (eg,ibuprofen600 to 800 mg orally every 6 to 8 hours). The intensity of therapy is dictated by the patient’s distress. Severe pain may require opioids.Colchicine0.5 to 1 mg orally once a day for 3 months as an adjunct significantly decreases the recurrence rate and symptom persistence in patients with a first episode of acute pericarditis and is increasingly being used as 1st-line therapy. Although most mild cases of idiopathic and viral pericarditis respond well within a week, the optimal duration of treatment is unclear. Typically, patients should be treated at least until any effusion and evidence of inflammation (eg, erythrocyte sedimentation rate, C-reactive protein levels) have resolved. Corticosteroids (eg,prednisone60 to 80 mg orally once a day for 1 week, followed by rapid tapering of the dose) may be used in patients with speciﬁc indications (eg, connective tissue disorder, autoimmune or uremic pericarditis, failure to respond tocolchicineor NSAIDs) but are not given routinely because they enhance viral multiplication and recurrence is common when the dosage is tapered;colchicinemay be particularly useful during the taper. An alternative approach is the use ofprednisoneat a lower dose (0.2 to 0.5 mg/kg orally once a day) for 2 to 4 weeks followed by a slow taper over ~ 3 months. Tuberculous and pyogenic pericarditis should be excluded before corticosteroid therapy is initiated. Intrapericardial instillation oftriamcinolone300 mg/m2avoids systemic adverse effects and is highly effective but is typically reserved for patients with recurrent or refractory disease. Anticoagulants are usually contraindicated in acute pericarditis because they may cause intrapericardial bleeding and even fatal tamponade; however, they can be given in early pericarditis complicating acute MI. Uncommonly (eg, with chronic constrictive pericarditis), pericardial resection is required. Painful recurrences of acute pericarditis may respond to NSAIDs and/orcolchicine0.5 mg orally twice a day for 6 to 12 months with a gradual taper. If these drugs do not suffice, corticosteroids may be tried, presuming the cause is not infectious. Refractory cases have been treated with interleukin-1 receptor antagonists (eg,anakinra,rilonacept). Infections are treated with specific antimicrobials. Complete drainage is often necessary. In postpericardiotomy syndrome, post-MI syndrome, or idiopathic pericarditis, antibiotics are not indicated. An NSAID at full doses may control pain and effusion. When required to control pain, fever, and effusion,prednisone(eg, 20 to 60 mg orally once a day) may be given for 3 to 4 days. If the response is satisfactory, the dose is gradually reduced, and the drug may be stopped in 7 to 14 days. But sometimes many months of treatment are needed. Beginning on postoperative day 3,colchicine1 mg orally once a day for 30 days, after a 2 mg load may reduce the incidence of postpericardiotomy syndrome after cardiac surgery.Aspirinshould be used when pericarditis occurs in patients with an acute myocardial infarction. For pericarditis due to rheumatic fever, another connective tissue disorder, or tumor, therapy is directed at the underlying process. For pericardial effusion due to trauma, surgery is sometimes required to repair the injury and remove blood from the pericardium. Pericarditis due to uremia may respond to increased frequency of hemodialysis, aspiration, or systemic or intrapericardial corticosteroids. Intrapericardialtriamcinolonemay be useful. Chronic effusions are best treated by treating the cause, if known. Recurrent or persistent symptomatic effusions may be treated with balloon pericardiotomy or a surgical pericardial window. Asymptomatic effusions of unknown cause may require only observation. Congestion in chronic constrictive pericarditis may be alleviated with salt restriction and diuretics.Digoxinis indicated only if atrial arrhythmias or ventricular systolic dysfunction is present. Patients with symptomatic constrictive pericarditis (eg, with dyspnea, unexplained weight gain, a new or increased pleural effusion, or ascites) and those with markers of chronic constriction (eg, cachexia, atrial fibrillation, hepatic dysfunction, pericardial calcification) usually require pericardial resection. However, patients with mild symptoms (because they derive little benefit), heavy calcification, or extensive myocardial damage may be poor surgical candidates. The mortality rate for pericardial resection may approach 40% in New York Heart Association (NYHA) functional class IV patients (see table New York Heart Association (NYHA) Classification of Heart Failure ). Patients who have constrictive pericarditis due to irradiation or a connective tissue disorder are especially likely to have severe myocardial damage and may not benefit from pericardial resection. Patients with newly diagnosed constrictive pericarditis who are hemodynamically stable and without evidence of chronic constriction may be given a 3-month trial of anti-inflammatory drugs, rather than pericardiectomy. Patients with pericardial inflammation on MRI may also benefit from a trial of medical therapy first, rather than pericardiectomy. 