What are the 2015 ESC recommendations for the treatment of pericarditis?

Updated: Apr 02, 2019
  • Author: Sean Spangler, MD; Chief Editor: Terrence X O'Brien, MD, MS, FACC  more...
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Answer

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).

 


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