Treatment of Cardiac Rubs After Heart Surgery
For symptomatic post-cardiac surgery pericardial friction rubs with evidence of systemic inflammation (fever, elevated CRP, chest pain), treat with NSAIDs or colchicine for several weeks to months; however, asymptomatic friction rubs alone without inflammatory markers do not require anti-inflammatory therapy. 1
Clinical Context and Pathophysiology
Pericardial friction rubs after cardiac surgery are a manifestation of post-cardiac injury syndrome (PCIS), also known as post-pericardiotomy syndrome (PPS). 1 This represents an immune-mediated inflammatory response triggered by surgical trauma to pericardial tissues, typically appearing days to weeks after surgery. 1 The syndrome is more common after valve surgery than isolated coronary artery bypass grafting. 1
Diagnostic Approach
Diagnosis requires at least 2 of 5 criteria: 1
- Fever without alternative causes
- Pericarditic or pleuritic chest pain
- Pericardial or pleural rubs
- Evidence of pericardial effusion
- Pleural effusion with elevated CRP
Critical distinction: The presence of a friction rub alone does not mandate treatment—you must demonstrate systemic inflammation (elevated CRP, fever) to justify anti-inflammatory therapy. 1 Pericardial rubs can persist even with large effusions or may be transient. 1
Perform echocardiography when PCIS is suspected to assess for effusion size and exclude tamponade. 1
Treatment Algorithm
For Symptomatic PCIS with Friction Rub:
First-line therapy: 1
- NSAIDs (such as ibuprofen) at full anti-inflammatory doses for several weeks to months, continuing even after effusion disappears 1
- OR Colchicine 1 mg/day (or 0.5 mg daily for patients <70 kg) for several weeks to months 1
- Continue treatment until symptoms resolve and CRP normalizes 2
Second-line therapy for refractory cases: 1
- Long-term oral corticosteroids (3-6 months): prednisone 1-1.5 mg/kg for at least one month, then taper over three months 1
- OR Pericardiocentesis with intrapericardial triamcinolone instillation (300 mg/m²) 1
For Asymptomatic Postoperative Effusions:
NSAIDs and colchicine are NOT indicated for asymptomatic post-surgical effusions without systemic inflammation, as this therapy may cause unnecessary side effects. 1 Colchicine specifically is not recommended for postoperative effusions in the absence of systemic inflammation. 1
Prevention Considerations
Colchicine is the only proven preventive strategy for post-pericardiotomy syndrome when given perioperatively, reducing the odds ratio to 0.38. 1 However, perioperative use carries increased gastrointestinal side effects compared to postoperative initiation. 1
Methylprednisolone and aspirin have not shown benefit for primary prevention. 1
Critical Pitfalls to Avoid
Anticoagulation risk: Warfarin administration in patients with early postoperative pericardial effusion poses the greatest risk for complications, particularly if pericardiocentesis and drainage are not performed. 1 Exercise extreme caution with anticoagulation in this setting.
Corticosteroid overuse: Avoid corticosteroids as first-line therapy—reserve them only for patients with contraindications to NSAIDs/colchicine or refractory symptoms, as they increase recurrence risk. 2, 3
Premature treatment cessation: Do not stop therapy until both symptoms resolve AND inflammatory markers (CRP) normalize. 2 When tapering corticosteroids, if symptoms recur, return to the last effective dose for 2-3 weeks before attempting to taper again. 1
Surgical intervention: Redo surgery and pericardiectomy are very rarely needed and should only be considered for highly symptomatic, medically refractory cases. 1 Patients should be steroid-free for several weeks before pericardiectomy. 1
Monitoring and Follow-up
Assess treatment response after 1 week. 2 Continue monitoring for development of cardiac tamponade, which can occur in up to one-third of patients with large chronic effusions. 1 Watch for triggers including hypovolemia, tachyarrhythmias, and intercurrent acute pericarditis. 1