Acute Pericarditis Treatment & Management

Oxygen and a cardiac monitor should be provided. Rule out other life-threatening causes of chest pain, such as myocardial infarction (MI) or aortic dissection. Evaluate for evidence of hemodynamic instability. Consider whether further management is safe to continue on an outpatient basis.

2015 European Society of Cardiology (ESC) recommendations

Outpatient versus inpatient treatment

The 2015 European Society of Cardiology (ESC) update of their 2004 guidelines on the diagnosis and management of pericardial diseases recommends managing patients considered to be low risk (no risk factors) on an outpatient basis, whereas those with at least one risk factor should be managed as inpatients (both class I, level B evidence). ^{[3, 4]} ​ After 1 week, evaluate the clinical response to anti-inflammatory therapy (class I, level B evidence). ^[3]

Fever above 100.4°F (38°C), subacute onset, immunosuppression, trauma, oral anticoagulation therapy, aspirin or nonsteroidal anti-inflammatory drug (NSAID) treatment failure, myopericarditis, severe pericardial effusion, and cardiac tamponade are considered poor prognostic predictors. ^{[3, 4, 42]} Patients without these factors were treated on an outpatient basis without serious complications after a mean follow-up of 38 months. ^[42]  Similar poor prognostic indicators were noted in a systematic review (fever of more than 100.4°F [38°C], subacute onset, unsuccessful NSAID therapy, large pericardial effusion or tamponade). ^[1]

Pericardial effusion (all class I, level C evidence) ^[3]

In patients with pericardial effusion, treat the underlying cause. In the setting of pericardial effusion and systemic inflammation, administer aspirin/NSAIDs/colchicine and treat pericarditis.

Cardiac tamponade (all level C evidence) ^[3]

Perform urgent pericardiocentesis or cardiac surgery for cardiac tamponade or for symptomatic moderate to large pericardial effusions refractory to medical therapy, as well as when an unknown bacterial or neoplastic etiology is suspected (class I).

To guide timing of pericardiocentesis, a judicious clinical evaluation including echocardiographic findings is recommended (class I).

Avoid vasodilators and diuretics in the presence of cardiac tamponade (class III).

Constrictive pericarditis (all level C evidence) ^[3]

Pericardiectomy is the treatment mainstay of chronic permanent constriction (class I). To prevent progression of constriction, administer medical therapy for specific pericarditis conditions (ie, tuberculous pericarditis) (class I).

Consider empiric anti-inflammatory therapy in the setting of transient or new diagnosis of constriction with concomitant evidence of pericardial inflammation (ie, elevated CRP or pericardial enhancement on computed tomography scan/cardiac magnetic resonance imaging) (class IIb).

Purulent pericarditis (all level C evidence) ^[3]

• Perform effective pericardial drainage (class I).
• Administer intravenous antibiotics (class I).
• Consider subxiphoid pericardiotomy and pericardial cavity rinsing (class IIa).
• Consider intrapericardial thrombolysis (class IIa).
• Consider pericardiectomy for dense adhesions, loculated/thick purulent effusion, tamponade recurrence, persistent infection, and progression to constriction (class IIa).

Pericarditis in renal failure (all level C evidence) ^[3]

• Consider dialysis in uremic pericarditis (class IIa).
• Consider intensifying dialysis in the setting of pericarditis despite adequate dialysis (class IIa); when intensive dialysis is ineffective, consider systemic or intrapericardial NSAIDs and corticosteroids (class IIb).
• Consider pericardial aspiration and/or drainage in the setting of nonresponse to dialysis (class IIb).
• Colchicine is contraindicated in the setting of pericarditis and severe renal impairment (class III).

Traumatic pericardial effusion and hemopericardium in aortic dissection ^[3]

• Perform immediate thoracotomy (class I, level B evidence), or consider pericardiocentesis as a bridge to thoracotomy (class IIb, level B evidence), in the setting of cardiac tamponade caused by penetrating heart and chest trauma.
• In the setting of aortic dissection with hemopericardium, consider controlled pericardial drainage of very small amounts of the hemopericardium as a temporary stabilizing measure for maintenance of blood pressure at about 90 mmHg (class IIa, level C evidence).

Chylopericardium (all level C evidence) ^[3]

• Consider pericardial drainage and parenteral nutrition in symptomatic or large uncontrolled effusion caused by chylopericardium (class IIa).
• Consider surgical therapy for chylopericardium if conservative management does not reduce pericardial drainage and the course of the thoracic duct is identified (class IIa).
• Consider octreotide therapy (100 μg subcutaneously [SC] three times daily for 2 weeks) (presumed mechanism of action: reduction in chyle production) (class IIb).

Other considerations

Avoid NSAIDs and corticosteroids in acute MI pericarditis, because they may interfere with ventricular healing, remodeling, or both.

Avoid corticosteroid therapy in viral pericarditis (class III, level C evidence). ^[3]

When cardiac irradiation is necessary, use radiation therapy methods that reduce the irradiation volume and the dose whenever possible (class I, level C evidence). ^[3]

For cases of complicated pericarditis, therapies targeting the inflammasome may result in more durable remission and resolution. ^[28]

Patients may require transfer to a hospital setting in which hemodialysis and cardiothoracic surgery are available.

For more information, see the Medscape Drugs and Diseases topics Constrictive Pericarditis, Constrictive-Effusive Pericarditis, and Pediatric Infective Pericarditis.

Patients with chest pain, regardless of etiology, should routinely be treated with oxygen and cardiac monitor.

Patients suspected of having pericarditis should have routine care as for patients with acute cardiac conditions. The initial prehospital care for suspected cardiac tamponade is the same as for any major trauma. The diagnosis may also be suspected based on the location of any penetrating wounds. The possibility of a tension pneumothorax should also be considered.

The emergency care of the patient centers on prompt diagnosis and treatment of potentially life-threatening entities. Thoracotomy and pericardiotomy may be required if the patient has rapid deterioration or cardiac arrest.

For acute pericarditis, the 2015 European Society of Cardiology (ESC) update of their 2004 guidelines on the diagnosis and management of pericardial diseases recommends the following (all class I, level A evidence) ^{[3, 4]} :

• Aspirin (750-1000 mg)  or nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen 600 mg), every 8 hours for 1-2 weeks, with gastric protection
• First-line therapy as adjunct to aspirin or NSAID therapy: Colchicine 0.5 mg daily (weight < 70 kg) or twice daily (weight ≥70 kg) for 3 months

Consider low-dose corticosteroids in cases of acute pericarditis when aspirin/NSAIDs and colchicine are contraindicated or have failed, and when an infectious cause has been excluded, or when there is a specific indication (eg, autoimmune disease) (class IIa, level C evidence). ^[3]  However, corticosteroids are not recommended as first-line therapy for acute pericarditis (class III, level C evidence). ^[3]

In the setting of recurrent pericarditis, the ESC recommends administering aspirin or NSAIDs at full doses, if tolerated, until symptomatic relief, with the addition of 6 months of colchicine (0.5 mg twice daily or 0.5 mg daily for those < 70 kg or intolerant to higher doses) (both class I, level A evidence). ^{[3, 4]}  In select cases, colchicine therapy longer than 6 months should be considered based on clinical response (class IIA, level C evidence). In cases of corticosteroid-dependent recurrent pericarditis refractory to colchicine, consider agents such as intravenous immunoglobulin (IVIG), anakinra, and azathioprine (class IIA, level C evidence).

Pericarditis

Ideally, echocardiography should be readily available to determine the presence or absence of a pericardial effusion (see Echocardiography under Workup). If no pericardial effusion is noted, stable patients with presumptive viral pericarditis may be discharged with appropriate instructions and follow-up care.

If a large effusion is present, the stable patient may undergo a pericardiocentesis or placement of a pericardial window (see Surgical Care).

Cardiac tamponade

Treatment for this condition depends on the patient’s stability. Unstable patients require immediate treatment of the increase in pericardial pressure with pericardiocentesis (see Surgical Care). Removing as little as 30-50 mL may produce dramatic hemodynamic improvement.

Patients may have subacute tamponade (intermittently decompressing) and may benefit from decompression in the operating room with cardiothoracic care available to treat cardiac injuries.

The treatment for specific types of pericarditis are briefly discussed in this section.

Use serum levels of C-reactive protein (CRP) to guide treatment duration and assess clinical response (class IIa, level C evidence). ^[3]

Idiopathic pericarditis

Treatment for this condition is similar to viral pericarditis and includes anti-inflammatory drugs to control symptoms and inflammation. ^[43] Colchicine may prevent recurrent pericarditis resistant to aspirin or nonsteroidal anti-inflammatory agents (NSAIDs). Steroids are not administered initially as their use is associated with an increased incidence of recurrent pericarditis. 

Infectious pericarditis

The treatment of viral pericarditis is based on the symptoms present, with observation for the development of tamponade. Treatment for bacterial pericarditis includes appropriate antibiotics for at least 4 weeks and drainage of pericardial fluid.

For fungal infection, the European Society of Cardiology (ESC) 2004 guideline recommends fluconazole, ketoconazole, itraconazole, amphotericin B, liposomal amphotericin B, or amphotericin B lipid complex for treatment of fungal infection. Corticosteroids and NSAIDs can be used to support the antifungal drug treatment. ^[32]

Intrapericardial fibrinolysis can be a useful treatment to assist with drainage of thick, loculated fluid, but open surgical drainage is preferred. Occasionally, patients require partial to total pericardiectomy.

Tubercular infection is managed with the usual antituberculous chemotherapy. The 2015 updated ESC guidelines recommend consideration of intrapericardial urokinase to reduce the risk of constriction in tuberculous effusive pericarditis (class IIb, level C evidence). ^[3]  

Controversy exists regarding the use of steroids in the treatment of tuberculous pericarditis. The ESC 2004 guideline advises using corticosteroid therapy only in patients with secondary tuberculous pericarditis, and only as an adjunct to tuberculostatic treatment. A meta-analysis of patients with effusive and constrictive TBC pericarditis found that tuberculostatic treatment, combined with steroids, might be associated with fewer deaths, less frequent need for pericardiocentesis or pericardiectomy. ^[24]

The 2015 ESC updated guidelines indicate adjunctive steroids may be considered in human immunodeficiency virus (HIV)-negative TB pericarditis, but these agents should be avoided in HIV-associated TB (class IIb, level C evidence). ^[3]  Regarding empiric anti-tuberculosis treatment in patients, ESC 2015 indicates the following (all level C evidence) ^[3] :

• Endemic regions: Recommended for exudative pericardial effusion after other causes have been ruled out (class I)
• Non-endemic regions: Not recommended in the absence of a diagnosis of tuberculous pericarditis after systematic investigation (class III)

In the setting of tuberculous pericardial constriction, 6 months of standard antituberculosis agents is recommended (class I, level C evidence). ^[3] If the patient's condition does not improve or deteriorates after 4-8 weeks of antituberculosis therapy, pericardiectomy is recommended. (class I, level C evidence). ^[3]

Use of adjunctive prednisolone in patients with acquired immunodeficiency syndrome (AIDS) may reduce mortality in this population.

Inflammatory pericarditis

Only symptomatic rheumatoid arthritis (RA) pericarditis should be treated. However, treat lupus pericarditis with anti-inflammatory agents and optimize systemic lupus erythematosus (SLE) treatment.

Rheumatic fever pericarditis resolves with anti-inflammatory treatment.

Metabolic pericarditis

The development of pericarditis in a patient with severe acute or chronic renal failure is an absolute indication for intensive dialysis. In most patients, relief of chest pain and reduction in the size of any effusion occurs within 1-2 weeks.

If no improvement is noted after 7-10 days or if the patient has hemodynamic instability, proceed with pericardiocentesis or pericardiectomy (see Surgical Care). The ESC 2004 guideline recommends pericardiocentesis for treating cardiac tamponade and large chronic effusions resistant to dialysis. ^[24] Intensive dialysis is beneficial to most patients with uremia who develop pericarditis before dialysis. Dialysis-induced pericarditis fails to respond to more intensive dialysis in 25-33% of patients.

Both hemodialysis and peritoneal dialysis are efficacious in the treatment of uremic pericarditis, though each technique has unique advantages and disadvantages. Hemodialysis may cause hypotension, which may be dangerous in the setting of tamponade. In addition, some physicians advocate heparin-free hemodialysis to reduce the risk of intrapericardial hemorrhage. Peritoneal dialysis may compromise respiratory function because of the effect of intraperitoneal fluid on the diaphragm.

In dialysis-associated pericarditis, an increased intensity of dialysis for 10-14 days is recommended. Close monitoring of fluid volume and electrolytes is mandatory to detect and correct hypophosphatemia and hypokalemia, which may occur with intensive dialysis. The response of dialysis-associated pericarditis is not predictable. In some instances, consider a switch to peritoneal dialysis if heparin-free dialysis cannot be performed.

NSAIDs and steroids may offer symptomatic relief but are not effective without dialysis. Indomethacin ameliorates fever, but it does not accelerate resolution of the effusion.

Early intervention with dialysis may prevent the development of uremic pericarditis. Maintenance of adequate dialysis therapy lessens the likelihood of a patient developing dialysis-associated pericarditis.

Treatment in hypothyroidism-associated pericarditis is hormone replacement.

The ESC 2004 guideline also recommends thyroid hormone therapy to decrease pericardial effusion. ^[32]

Cardiovascular pericarditis

Pericarditis does not contraindicate thrombolytic or anticoagulant therapy for an acute MI. However, anticoagulation should be discontinued if pericardial effusion develops or effusion size increases. Treatment is with aspirin.

In Dressler syndrome, anticoagulant therapy should be stopped because of the risk of hemorrhagic pericarditis. Treatment is with NSAIDs.

Miscellaneous conditions

Neoplasm-associated pericarditis

With neoplasm-associated pericarditis, initial treatment includes relief of tamponade, confirmation of the diagnosis, and systemic treatment of the neoplasm. Further treatment options include sclerosis of the pericardial space, instillation of chemotherapeutic agents into the pericardial space, local radiation, or pericardiectomy. ^{[3, 44]}

The ESC 2004 guideline and its 2015 update indicate that prevention of recurrences of neoplastic pericarditis may be achieved via intrapericardial instillation of sclerosing, cytotoxic agents, or immunomodulators. ^{[3, 44]}  Intrapericardial treatment tailored to the type of tumor shows that administration of cisplatin is most effective in secondary lung cancer and intrapericardial instillation of thiotepa was more effective in breast cancer or pericardial metastases. ^{[3, 45, 44]}  

The ESC 2004 guideline and its 2015 update states that treatment of cardiac tamponade is a class I indication for pericardiocentesis in the presence of neoplastic pericarditis. ^{[3, 32]} In suspected neoplastic pericardial effusion without tamponade, the following are recommended ^[32] :

• Systemic antineoplastic treatment as baseline therapy

• Pericardiocentesis to relieve symptoms and to confirm diagnosis

• Intrapericardial instillation of cytostatic/sclerosing agent

Drug-induced pericarditis treatment includes stopping the administration of the offending agent and anti-inflammatory therapy as needed. Treatment is with aspirin or NSAIDs.

Colchicine is effective in the prevention of postpericardiotomy syndrome and may halve the risk of developing this syndrome when used following cardiac surgery. ^[46]

Imazio et al found evidence that in patients with acute pericarditis, colchicine, when added to conventional anti-inflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis. ^[47] In a trial of 240 adults with acute pericarditis randomly assigned to receive colchicine (n = 120) or placebo (n = 120) for 3 months in addition to conventional anti-inflammatory therapy with aspirin or ibuprofen, the primary study outcome of incessant or recurrent pericarditis occurred in 20 patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group. Colchicine reduced the rate of symptom persistence at 72 hours, the number of recurrences per patient, and the hospitalization rate. Furthermore, colchicine improved the remission rate at 1 week. Both groups had similar overall adverse effects and rates of study-drug discontinuation, and no serious adverse events were reported. ^[47]

Surgical procedures for pericarditis include pericardiectomy for constrictive pericarditis, as well as pericardiocentesis, pericardial window placement, or pericardiotomy to drain pericardial fluid.

Pericardiectomy

Pericardiectomy is the most effective surgical procedure for managing large effusions, because it has the lowest associated risk of recurrent effusions. This procedure is used for constrictive pericarditis, effusive pericarditis, or recurrent pericarditis with multiple attacks, steroid dependence, and/or intolerance to other medical management.

Consider pericardiectomy for radiation-induced constrictive pericarditis, but with a worse outcome than when performed for constrictive pericarditis from other causes, because of coexisting myopathy (class IIa, level B evidence). ^[3]

Pericardiectomy requires general anesthesia and a thoracotomy; therefore, pericardiectomy should be considered only if pericardiotomy cannot be performed or has been unsuccessful. ^[48]

Studies demonstrate that failure rates are proportional to the amount of pericardium removed (ie, the more pericardium removed, the less likely the procedure will fail). In effusive pericarditis, the higher failure rate associated with a pericardial window procedure or partial pericardiectomy is likely secondary to the continued fluid production from the remaining pericardium, with sealing of the remaining pericardium to the heart.

The operative mortality rate was 14% in one series, with a range of 1% for New York Heart Association (NYHA) class 1-2, 10% for class 3, and 46% for class 4. The 5-year survival rate was 80% for class 3-4 and approximately 95% for 1-2.

As with pericardiocentesis, studies involving pericardiectomy note a greatly improved diagnostic yield if pericardial biopsy is performed as part of a therapeutic procedure. Diagnostic biopsies yielded 5%, whereas therapeutic biopsies were at 22-54%.

A study by Thompson et al indicated that complete pericardiectomy can produce good outcomes in properly selected pediatric patients with pericarditis. ^[49] The report involved 27 pediatric patients (mean age, 16.7 y), including 16 patients with inflammatory pericarditis and 11 with constrictive pericarditis. The median presurgical period of symptom duration for these patients was 1 year. Before the pericardiectomies were performed, 10 patients had been hospitalized for treatment of symptoms, 15 had undergone pericardiocentesis, and 3 had already undergone a partial pericardiectomy. ^[49]

The procedures in the above study consisted of complete pericardiectomy (21 patients), biventricular pericardiectomy (3 patients), and completion pericardiectomy (3 patients). The postoperative course was, for most of the patients, uneventful, although one patient with radiation-induced heart disease died of acute hepatic failure 155 days after undergoing pericardiectomy. ^[49] At follow-up (median period, 1 y), 89% of the patients had experienced complete symptom resolution.

Pericardiocentesis

People with effusions larger than 250 mL, effusions in which size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade are candidates for pericardiocentesis (for the technique, see Pericardiocentesis under Workup).

The image below shows preprocedure and postprocedure images of a cardiac silhouette.

Pericardial window placement

In critically ill patients, a balloon catheter may be used to create a pericardial window, in which only 9 cm² or less of pericardium is resected. This procedure is a modification of balloon valvuloplasty in which an uninflated balloon is passed inside the pericardial space, where it is opacified, inflated, and then pulled through the pericardium to create a window through which pericardial fluid drains into the peritoneal or pleural space.

Pericardial window placement is used for effusive pericarditis therapy. Some studies note the need for repeat operation in nearly 25% of patients who undergo the procedure at 2 years.

Consider the creation of a pericardial window via left minithoracotomy in the surgical management of malignant cardiac tamponade (class IIb, level B evidence). ^[3]

Pericardiotomy

Consider subxiphoid pericardiotomy for large effusions that do not resolve. This procedure may be performed under local anesthesia and has a lower risk of complications compared with pericardiectomy.

The European Society of Cardiology (ESC) 2004 guideline recommends percutaneous balloon pericardiotomy, which creates a pleuro-pericardial direct communication, allowing for drainage of fluid into the pleural space. ^[32] In large malignant pericardial effusions and recurrent tamponade, it appears to be a safe and effective (90-97%) intervention. ^[32]  Consider percutaneous balloon pericardiotomy to prevent recurrence of neoplastic pericardial effusions (class IIb, level B evidence). ^[3]

Post-cardiac injury syndromes (PCIS)

The 2015 ESC updated guidelines have the following recommendations for patients with PCIS ^[3] :

• Administer anti-inflammatory therapy to speed up symptomatic remission and reduce recurrences (class I, level B evidence).
• Aspirin is first line for anti-inflammatory therapy of post-myocardial infarction (MI) pericarditis, as well as for individuals receiving antiplatelet therapy (class I, level C evidence).
• Consider adding colchicine to aspirin/NSAIDs to treat PCIS, as for treating acute pericarditis (class IIa, level B evidence).
• To prevent postpericardiotomy syndrome, consider administering post-cardiac surgery colchicine using weight-adjusted doses (ie, ≤70 kg: 0.5 mg once daily; >70 kg: 0.5 mg twice daily) and without a loading dose, for 1 month, providing there are no contraindications and it is tolerated (class IIa, level A evidence).
• Consider careful echocardiographic follow-up every 6-12 months after PCIS to exclude potential development of constrictive pericarditis, based on the patient's clinical features and symptoms (class IIa, level C evidence).

The following conditions are possible complications of acute pericarditis itself or treatment used in its management:

• Recurrence in 15-32% of patients

• Cardiac tamponade

• Constrictive pericarditis. In addition, liver disease has been reported in asymptomatic constrictive pericarditis

• Combination of effusive and constrictive pericarditis

• Noncompressive effusion

• Cardiac perforation with pericardiocentesis

Bronchopericardial fistula has been reported as a complication of multi–drug-resistant tuberculosis in a patient with human immunodeficiency virus (HIV) infection. ^[50]

Consult a cardiologist or internist for acute and idiopathic cases of pericarditis. In complicated cases (eg, tuberculous, traumatic pericardial injury, purulent uremic etiologies require multidisciplinary involvement) obtain consultations with a cardiologist, cardiac and/or trauma surgeon, and medical subspecialists (eg, infectious diseases specialist, nephrologist).

Consult with a cardiothoracic surgeon for all patients with large effusions. Development of tamponade is unpredictable, and it is important for the surgeon to be aware of the patient if an emergent procedure is necessary.

In patients with uremic or dialysis-associated pericarditis, carefully monitor the patient at follow-up hemodialysis visits for recurrence of signs or symptoms. Up to 15% of these patients may have recurrence of pericarditis.

Diet

Patients on dialysis require a daily diet restricted to 1.2 g/kg of protein, 2 g of sodium, and 2 g of potassium. Patients on peritoneal dialysis may require less stringent protein restriction.

Activity

Activity should be limited to avoid strenuous activities or trauma, which may increase the risk of hypotension or arrhythmias.

The 2015 ESC update of their 2004 guidelines recommends the following regarding activities in individuals with acute or recurrent pericarditis (both class IIa, level C evidence) ^[3] :

• Non-athletes: Consider exercise restriction until symptomatic resolution and normalization of C-reactive protein (CRP), electrocardiography (ECG), and echocardiography.
• Athletes: Consider at least 3 months of exercise restriction until symptomatic resolution and normalization of CRP, ECG, and echocardiography.