Emergency Physicians' Guide to Managing Pericardial Diseases
Emergency Physicians' Guide to Managing Pericardial Diseases
Acute pericarditis must be included in the differential diagnosis of any patient who presents to the emergency department with chest pain. Electrocardiograms (ECGs) from patients that demonstrate ST-segment elevation are another red flag for pericarditis. We've previously considered some of the diagnostic dilemmas associated with pericarditis in this series,but controversy exists regarding the proper management of patients. Imazio and colleagues surveyed the literature to address some of the controversy and confusion regarding management of patients with pericardial disease.
Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y
Circulation. 2010;121:916-928
The basic diagnostic workup for pericardial diseases should include a patient history and physical examination, ECG, blood tests (including markers of inflammation [eg, C-reactive protein or erythrocyte sedimentation rate] and myocardial necrosis [troponin]), chest X-ray, and transthoracic echocardiography. The authors do not indicate specifically whether echocardiography should be an emergent test, but it probably can be obtained urgently rather than emergently in stable patients. Additional tests (eg, renal function and tuberculosis testing) should be related to the suspected origin of the pericarditis. Of note, idiopathic and infectious causes account for two thirds of cases of pericardial disease; viruses (usually echovirus or coxsackievirus) account for the majority of cases. The major specific causes that need to be ruled out are tuberculous pericarditis, neoplastic pericarditis, and pericarditis associated with a systemic disease. Tuberculous pericarditis has a high incidence in sub-Saharan Africa (70%-80%) and is associated with HIV infection (>90%); pericarditis may also be found in developed countries, especially among immigrants from areas with a high prevalence of tuberculosis and HIV infection.
Five factors have been validated as predicting a poor prognosis:
Patients with any of these factors should be admitted and receive an aggressive workup for underlying cause.
Although they have not yet been validated, 4 additional factors that may predict poor outcome are:
Although idiopathic causes account for many cases of acute pericarditis, up to 90% of cases of moderate to large effusions are associated with a specific cause, including neoplasms, tuberculosis, and myxedema. Pericardiocentesis is indicated for cardiac tamponade; when there is a high suspicion of tuberculous, purulent, or neoplastic pericarditis; and for large effusions and effusions that are refractory to medical treatment. Pericardiocentesis is best performed under fluoroscopic or echocardiographic guidance. In nonemergent conditions, performance of pericardiocentesis in the catheterization laboratory is ideal.
The widespread ST-segment elevation. that is normally attributed to acute pericarditis is actually due to concomitant myocardial involvement (the pericardium is considered electrocardiographically silent). Myocardial involvement will often produce troponin elevation.
Myocarditis and pericarditis share similar etiologic agents, and the 2 entities often coexist, with varying degrees of myocardial and pericardial involvement. Cases in which pericarditis predominates are often referred to as "myopericarditis," and cases in which myocarditis predominates are often referred to as "perimyocarditis"; cases of pure pericarditis and pure myocarditis also exist.
Myopericarditis is generally associated with fairly preserved left ventricular ejection fraction and has a good prognosis without progression to heart failure or recurrence. Lower doses of anti-inflammatory drugs (aspirin 500 mg 3 times daily) are recommended for 1-2 weeks when myocardial involvement is suspected. This recommendation is based on animal studies indicating that these agents enhance the myocarditic process and increase mortality For these patients, exercise restriction is recommended for 4-6 weeks, and echocardiographic monitoring of ventricular function at 1, 6, and 12 months is recommended. Return to competitive sports can be considered after 6 months
Corticosteroids are recognized as a risk factor for pericarditis recurrence, probably because of impaired virus clearance, and they should generally not be initiated in the emergency department. Aspirin or NSAIDs are the mainstay of treatment for acute pericarditis. Treatment failure is often the result of using dosages that are too low or treatment courses that are too short. Examples of recommended starting dosages are aspirin 2-4 g daily, indomethacin 75-150 mg daily, or ibuprofen 1600-3200 mg daily; treatment should continue until the C-reactive protein level normalizes. Aspirin is the preferred agent in patients with atherosclerotic heart disease.
Colchicine is recommended as adjunctive treatment for recurrent pericarditis (in preference to steroids) and is also considered useful in acute pericarditis. Colchicine use is associated with a more than 50% reduction in recurrence rate and a marked decrease in persistence of symptoms at 72 hours. The main side effect is diarrhea, occurring in 5%-10% of patients. The typical dose is 0.6 mg twice daily for 3-6 months; in cases of severe recurrence, the duration may be extended to 12-24 months. Patients weighing less than 70 kg should reduce the dose to 0.6 mg once daily. Colchicine is best used as adjunctive treatment (in addition to aspirin or NSAIDs) rather than as monotherapy.
Uncomplicated cases should be followed up in 7-10 days to assess response to therapy. Repeat visits should be planned to check the C-reactive protein level, and patients should return if symptoms recur.
The article also describes issues pertaining to refractory cases, long-term outcomes, interventional techniques, and management of chronic pericardial effusion.
When I was in medical school and residency, it was almost unheard of to discharge a patient with acute pericarditis home from the emergency department. However, as emergency department and hospital overcrowding continues to increase nationally, we are forced with increasing frequency to consider discharging such patients, often because in-hospital resources are too limited. Fortunately, new data have shown that patients without high-risk criteria can safely be discharged home. New data are also clarifying which patients need urgent in-hospital evaluation and the similarities and distinctions between pericarditis and myocarditis. It is incumbent on every emergency physician to understand the conditions under which patients can be safely discharged home, the conditions under which patients must be admitted for a workup, and the proper acute treatment modalities for these patients.
Abstract
Introduction
Acute pericarditis must be included in the differential diagnosis of any patient who presents to the emergency department with chest pain. Electrocardiograms (ECGs) from patients that demonstrate ST-segment elevation are another red flag for pericarditis. We've previously considered some of the diagnostic dilemmas associated with pericarditis in this series,but controversy exists regarding the proper management of patients. Imazio and colleagues surveyed the literature to address some of the controversy and confusion regarding management of patients with pericardial disease.
Controversial Issues in the Management of Pericardial Diseases
Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y
Circulation. 2010;121:916-928
Etiologic Search and Hospitalization
The basic diagnostic workup for pericardial diseases should include a patient history and physical examination, ECG, blood tests (including markers of inflammation [eg, C-reactive protein or erythrocyte sedimentation rate] and myocardial necrosis [troponin]), chest X-ray, and transthoracic echocardiography. The authors do not indicate specifically whether echocardiography should be an emergent test, but it probably can be obtained urgently rather than emergently in stable patients. Additional tests (eg, renal function and tuberculosis testing) should be related to the suspected origin of the pericarditis. Of note, idiopathic and infectious causes account for two thirds of cases of pericardial disease; viruses (usually echovirus or coxsackievirus) account for the majority of cases. The major specific causes that need to be ruled out are tuberculous pericarditis, neoplastic pericarditis, and pericarditis associated with a systemic disease. Tuberculous pericarditis has a high incidence in sub-Saharan Africa (70%-80%) and is associated with HIV infection (>90%); pericarditis may also be found in developed countries, especially among immigrants from areas with a high prevalence of tuberculosis and HIV infection.
Five factors have been validated as predicting a poor prognosis:
Fever > 38 C;
Subacute onset;
Large pericardial effusion;
Cardiac tamponade; and
Lack of response to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) after at least 1 week of therapy.
Patients with any of these factors should be admitted and receive an aggressive workup for underlying cause.
Although they have not yet been validated, 4 additional factors that may predict poor outcome are:
Myopericarditis;
Immunodepression;
Trauma; and
Oral anticoagulant therapy.
Pericardial Effusion
Although idiopathic causes account for many cases of acute pericarditis, up to 90% of cases of moderate to large effusions are associated with a specific cause, including neoplasms, tuberculosis, and myxedema. Pericardiocentesis is indicated for cardiac tamponade; when there is a high suspicion of tuberculous, purulent, or neoplastic pericarditis; and for large effusions and effusions that are refractory to medical treatment. Pericardiocentesis is best performed under fluoroscopic or echocardiographic guidance. In nonemergent conditions, performance of pericardiocentesis in the catheterization laboratory is ideal.
Myopericarditis
The widespread ST-segment elevation. that is normally attributed to acute pericarditis is actually due to concomitant myocardial involvement (the pericardium is considered electrocardiographically silent). Myocardial involvement will often produce troponin elevation.
Myocarditis and pericarditis share similar etiologic agents, and the 2 entities often coexist, with varying degrees of myocardial and pericardial involvement. Cases in which pericarditis predominates are often referred to as "myopericarditis," and cases in which myocarditis predominates are often referred to as "perimyocarditis"; cases of pure pericarditis and pure myocarditis also exist.
Myopericarditis is generally associated with fairly preserved left ventricular ejection fraction and has a good prognosis without progression to heart failure or recurrence. Lower doses of anti-inflammatory drugs (aspirin 500 mg 3 times daily) are recommended for 1-2 weeks when myocardial involvement is suspected. This recommendation is based on animal studies indicating that these agents enhance the myocarditic process and increase mortality For these patients, exercise restriction is recommended for 4-6 weeks, and echocardiographic monitoring of ventricular function at 1, 6, and 12 months is recommended. Return to competitive sports can be considered after 6 months
Anti-inflammatory Therapy
Corticosteroids are recognized as a risk factor for pericarditis recurrence, probably because of impaired virus clearance, and they should generally not be initiated in the emergency department. Aspirin or NSAIDs are the mainstay of treatment for acute pericarditis. Treatment failure is often the result of using dosages that are too low or treatment courses that are too short. Examples of recommended starting dosages are aspirin 2-4 g daily, indomethacin 75-150 mg daily, or ibuprofen 1600-3200 mg daily; treatment should continue until the C-reactive protein level normalizes. Aspirin is the preferred agent in patients with atherosclerotic heart disease.
Colchicine is recommended as adjunctive treatment for recurrent pericarditis (in preference to steroids) and is also considered useful in acute pericarditis. Colchicine use is associated with a more than 50% reduction in recurrence rate and a marked decrease in persistence of symptoms at 72 hours. The main side effect is diarrhea, occurring in 5%-10% of patients. The typical dose is 0.6 mg twice daily for 3-6 months; in cases of severe recurrence, the duration may be extended to 12-24 months. Patients weighing less than 70 kg should reduce the dose to 0.6 mg once daily. Colchicine is best used as adjunctive treatment (in addition to aspirin or NSAIDs) rather than as monotherapy.
Follow-up
Uncomplicated cases should be followed up in 7-10 days to assess response to therapy. Repeat visits should be planned to check the C-reactive protein level, and patients should return if symptoms recur.
The article also describes issues pertaining to refractory cases, long-term outcomes, interventional techniques, and management of chronic pericardial effusion.
Viewpoint
When I was in medical school and residency, it was almost unheard of to discharge a patient with acute pericarditis home from the emergency department. However, as emergency department and hospital overcrowding continues to increase nationally, we are forced with increasing frequency to consider discharging such patients, often because in-hospital resources are too limited. Fortunately, new data have shown that patients without high-risk criteria can safely be discharged home. New data are also clarifying which patients need urgent in-hospital evaluation and the similarities and distinctions between pericarditis and myocarditis. It is incumbent on every emergency physician to understand the conditions under which patients can be safely discharged home, the conditions under which patients must be admitted for a workup, and the proper acute treatment modalities for these patients.
Abstract