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] :
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Aspirin (750-1000 mg) or nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen 600 mg), every 8 hours for 1-2 weeks, with gastric protection
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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).
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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.
