Acute Pericarditis Medication

  • Author: Sean Spangler, MD; Chief Editor: Joseph L Fredi, MD   more...
 
Updated: Oct 10, 2011
 

Medication Summary

Treatment for specific causes of pericarditis is directed according to the underlying cause. For patients with idiopathic or viral pericarditis, therapy is directed at symptom relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy. These agents have a similar efficacy with relief of chest pain in about 85-90% of patients within days of treatment. Ibuprofen has the advantage of few adverse effects and increased coronary flow. Indomethacin has a poor adverse effect profile and reduces coronary flow.

A full-dose NSAID should be used (aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d). Treatment should last 7-14 days. A full-dose NSAID should be maintained until normalization of the C-reactive protein (CRP) followed by gradual tapering of the drug for another 1-2 weeks to prevent early reoccurrence.[6]

Aspirin is recommended for treatment of pericarditis after ST-elevation myocardial infarction (STEMI).

According to the 2004 ESC, corticosteroids can be used for refractory symptoms, but their use can delay myocardial infarction healing.[19]

Colchicine, in combination with an NSAID can be considered in the initial treatment to prevent recurrent pericarditis. Colchicine, alone or in combination with an NSAID, can be considered for patients with recurrent or continued symptoms beyond 14 days.

Several small studies have noted successful use of colchicine to prevent recurrence of acute pericarditis after failure of conventional treatment, especially in idiopathic cases.[32, 33, 34, 35] One report found marked improvement following corticosteroid therapy in a patient with refractory uremic pleuropericarditis.[27]

Corticosteroids should not be used for initial treatment of pericarditis unless it is indicated for the underlying disease, the patient’s condition has no response to NSAIDs or colchicine, or both agents are contraindicated.

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Nonsteroidal anti-inflammatory drugs

Class Summary

Because pericarditis is primarily due to inflammation, anti-inflammatory medications are considered the drugs of choice. These agents are effective for chest discomfort and underlying inflammation. However, although nonsteroidal-anti-inflammatory drugs (NSAIDs) may offer symptomatic relief, they are ineffective in uremic pericarditis absence of dialysis.

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Indomethacin (Indocin)

 

Indomethacin is the classic treatment used in pericarditis and is often considered the first choice. This drug is rapidly absorbed, and it is metabolized in the liver by demethylation, deacetylation, and glucuronide conjugation. Although, indomethacin ameliorates fever, it does not accelerate resolution of effusion.

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Ketorolac

 

Ketorolac is used for the relief of mild to moderate pain and inflammation. This agent inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Small studies have documented rapid relief of symptoms with 1-2 doses of ketorolac. Doses of more than 75 mg do not increase therapeutic effects; therefore, administer high doses with caution, and closely observe patient response.

Ibuprofen (Motrin, Advil)

 

Ibuprofen is usually the drug of choice for mild to moderate pain, if no contraindications exist. This drug inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in decreased prostaglandin synthesis.

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Ketoprofen

 

Ketoprofen is used to relieve mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses of more than 75 mg do not increase therapeutic effects; therefore, administer high doses with caution, and closely observe patient response.

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Naproxen (Anaprox, Naprelan, Naprosyn)

 

Naproxen is indicated for the relief of mild to moderate pain. This agent acts by inhibiting inflammatory reactions and pain via decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

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Anti-inflammatory agents

Class Summary

Anti-inflammatory agents reduce the effects of immune reactions.

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Colchicine

 

Colchicine is used for recurrent pericarditis. This agent acts by decreasing the leukocyte motility and phagocytosis observed in inflammatory responses.

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Salicylates

Class Summary

Salicylates reduce inflammation.

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Aspirin (Anacin, Bayer Aspirin, Ascriptin)

 

Aspirin is used for pericarditis secondary to myocardial infarction. This drug inhibits prostaglandin synthesis and blocks prostaglandin synthetase action, which prevents formation of the platelet-aggregating thromboxane A2. Use caution in pregnant women, because full doses are unsafe during pregnancy.

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Corticosteroids

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. These agents modify the body's immune response to diverse stimuli. However, although corticosteroids may offer symptomatic relief, they are ineffective in uremic pericarditis in the absence of dialysis.

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Prednisone ( Sterapred)

 

May decrease inflammation by reversing increased capillary permeability and by suppressing PMN activity.

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Contributor Information and Disclosures
Author

Sean Spangler, MD  Cardiologist, William Beaumont Army Medical Center

Sean Spangler, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Christopher A Fly, MD  Assistant Professor, Department of Emergency Medicine, Medical College of Georgia

Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Philip J Gentlesk, MD  Director, Cardiac Electrophysiology, Section of Cardiovascular Disease, Brooke Army Medical Center

Philip J Gentlesk, MD is a member of the following medical societies: American College of Cardiology and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Anupama Gowda, MBBS, MD  Consulting Staff, Atlanta Nephrology Associates, PC

Disclosure: Nothing to disclose.

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James W Lohr, MD  Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Genzyme Honoraria Speaking and teaching

G Shawn Lynchard, MD  Consulting Cardiologist, Medical Director of Cardiac Care Unit, Congestive Heart Failure Clinic, and ECG and Stress Testing Clinic, Brooke Army Medical Center

G Shawn Lynchard, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Chike Magnus Nzerue, MD  Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

David A Peak, MD  Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Verena T Valley, MD  Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital

Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steven J Compton, MD, FACC, FACP  Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Chief Editor

Joseph L Fredi, MD  Assistant Professor of Medicine, Director of Acute MI Program, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center

Joseph L Fredi, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

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This 12-lead electrocardiogram is representative of pericarditis.
Stage 1 electrocardiograph changes in a patient with acute pericarditis.
Stage 2 ECG changes in patient with acute pericarditis obtained 3 days into clinical course.
Stage 3 electrocardiograph changes of acute pericarditis obtained 18 days into the clinical course. The patient had resolution of symptoms.
Stage 4 electrocardiograph changes in the same patient as in the previous images, taken approximately 3 months after acute pericardial illness. The patient remained symptom free despite continued T-wave inversion.
Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Courtesy of Zhi Zhou, MD.
Recording of aortic pressure showing pulsus paradoxus. During inspiration, systolic pressure declines 20 mm Hg. Courtesy of Zhi Zhou, MD.
This ultrasonogram demonstrates a normal subcostal 4-chamber view of the heart. The pericardium is brightly reflective (echogenic or white in appearance). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
This is a modified subcostal ultrasonographic view of the heart in which a thick anechoic (dark or black) stripe is seen surrounding the heart (H). The stripe represents a large amount of fluid (F) in the pericardium, indicating tamponade.
A subcostal ultrasonographic view of the heart in a patient who sustained a stab wound to the chest. A hemopericardium (Hem) can be seen surrounding the heart (II).
The ultrasonogram demonstrates a subcostal view of the heart with a large fat pad (black arrows) present anteriorly.
 
 
 
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