What are the recommended tests and treatment for pericarditis?

From the Guidelines

For pericarditis, the recommended diagnostic tests include an ECG, chest X-ray, echocardiogram, and blood tests such as cardiac biomarkers, complete blood count, and inflammatory markers like C-reactive protein and erythrocyte sedimentation rate, as outlined in the 2015 ESC guidelines 1. The initial diagnostic work-up should aim to identify the underlying cause of pericarditis, with a focus on ruling out major causes such as bacterial pericarditis, neoplastic pericarditis, and pericarditis associated with systemic diseases 1. Some key points to consider in the diagnostic work-up include:

• Auscultation, ECG, transthoracic echocardiography, chest X-ray, and routine blood tests are recommended in all cases of suspected pericarditis 1
• Additional testing, such as CT and/or CMR, may be considered as second-level testing for diagnostic workup in pericarditis 1
• Pericardiocentesis or surgical drainage may be indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis 1 Treatment primarily involves NSAIDs as first-line therapy, typically ibuprofen (600-800mg three times daily) or aspirin (650-1000mg three to four times daily) for 1-2 weeks, followed by a gradual taper over 2-4 weeks, with colchicine added to NSAIDs for 3 months in acute cases and 6 months for recurrent cases to reduce recurrence risk, as recommended in the 2015 ESC guidelines 1. Some key points to consider in the treatment of pericarditis include:
• Colchicine use (0.5 mg twice or once daily for patients < 70 kg or intolerant to higher doses) is recommended as first-line therapy for acute pericarditis as an adjunct to aspirin/NSAIDs therapy (3 months) and is also recommended for recurrent pericarditis (6 months) 1
• Corticosteroids are not recommended as first-line therapy for acute pericarditis, but may be reserved for cases refractory to NSAIDs or when NSAIDs are contraindicated, with a slow taper over weeks to months 1
• Rest and activity restriction, particularly avoiding competitive sports until resolution of symptoms and normalization of inflammatory markers, is essential to prevent complications 1

From the Research

Diagnostic Tests for Pericarditis

• Electrocardiogram (ECG): The ECG is a useful tool in the diagnosis of pericarditis, with typical findings including diffuse concave-upward ST-segment elevation and PR-segment depression 2.
• Echocardiography: Transthoracic echocardiography is the first and most important initial diagnostic imaging modality in most patients affected by pericardial disease 3.
• Cardiac Computed Tomography (CCT) and Cardiac Magnetic Resonance Imaging (CMR): These advanced techniques have a pivotal role in the evaluation and guiding therapy of pericardial disease, with CMR identifying pericardial inflammation and CCT evaluating pericardial calcification 3.
• Imaging of Cardiac Infections: A comprehensive review and investigation flowchart for diagnostic workup, including echocardiography, cardiac CT, and magnetic resonance imaging, is useful in the diagnosis of pericarditis and other cardiac infections 4.

Treatment and Management of Pericarditis

• The treatment of pericarditis depends on the underlying cause, with anti-inflammatory medications and colchicine being common treatments.
• In cases of constrictive pericarditis, surgical pericardiectomy may be necessary, with echocardiography providing important diagnostic criteria for constrictive pericarditis 5.
• The use of ECG changes, such as widespread ST-segment elevation, can help identify patients with pericarditis, although these changes may also reflect concurrent myocarditis 6.

Key Findings and Recommendations

• ECG changes are reported in about one-quarter of patients with pericarditis, and are not associated with a worse prognosis 6.
• The presence of ventricular septal shift, preserved or increased medial mitral annular e' velocity, and prominent hepatic vein expiratory diastolic flow reversals are independently associated with the diagnosis of constrictive pericarditis 5.
• A comprehensive diagnostic workup, including echocardiography, cardiac CT, and magnetic resonance imaging, is essential for the accurate diagnosis and management of pericarditis 4.