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 at least 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. [13]
Aspirin is recommended for treatment of pericarditis after ST-elevation myocardial infarction.
According to the 2004 ESC, corticosteroids can be used for refractory symptoms, but their use can delay myocardial infarction healing. [32]
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. [51, 52, 53, 54] One report found marked improvement following corticosteroid therapy in a patient with refractory uremic pleuropericarditis. [45]
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.
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.
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.
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.
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.
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.
Anti-inflammatory agents
Class Summary
Anti-inflammatory agents reduce the effects of immune reactions.
Colchicine
Colchicine is used for recurrent pericarditis. This agent acts by decreasing the leukocyte motility and phagocytosis observed in inflammatory responses.
Salicylates
Class Summary
Salicylates reduce inflammation.
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.
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.
Prednisone ( Sterapred)
May decrease inflammation by reversing increased capillary permeability and by suppressing PMN activity.
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Stage 1 electrocardiograph changes in a patient with acute pericarditis.
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Stage 4 electrocardiograph changes in the same patient as in the previous image, taken approximately 3 months after acute pericardial illness. The patient remained symptom free despite continued T-wave inversion.
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Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Courtesy of Zhi Zhou, MD.
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Recording of aortic pressure showing pulsus paradoxus. During inspiration, systolic pressure declines 20 mm Hg. Courtesy of Zhi Zhou, MD.
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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. Part B courtesy of Wikimedia Commons/Patrick J Lynch and C Carl Jaffe.
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H&E stain, medium power magnification showing a rheumatoid nodule in rheumatoid pericarditis, composed of histiocytes and scattered multinucleated giant cells (lower right) surrounding necroinflammatory debris (upper left).
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Pap stain, high power magnification of adenocarcinoma metastatic to the pericardium on pericardiocentesis with the red arrow showing a normal mesothelial cell and the black arrowhead showing adenocarcinoma.
