Management of Pericarditis
First-line treatment for pericarditis consists of aspirin or NSAIDs plus colchicine, with therapy guided by symptom resolution and CRP normalization. 1
Diagnosis
Acute pericarditis is diagnosed when at least 2 of the following 4 criteria are present:
- Sharp, pleuritic chest pain that worsens when supine (~90% of cases) 2
- New widespread ST-segment elevation and PR depression on ECG (~25-50% of cases) 2
- New or increased pericardial effusion (~60% of cases) 2
- Pericardial friction rub (<30% of cases) 2
Risk Stratification
Patients should be triaged based on risk factors:
High-risk features (requiring hospitalization):
- Fever >38°C
- Subacute onset
- Large pericardial effusion
- Cardiac tamponade
- Failure to respond to NSAIDs after at least 1 week
- Immunosuppression
- Trauma
- Oral anticoagulant therapy
- Myopericarditis with troponin elevation
Low-risk features (outpatient management):
- Absence of high-risk features
- Good response to NSAIDs
Treatment Algorithm
1. Acute Pericarditis (First Episode)
First-line therapy:
- NSAIDs:
- PLUS Colchicine:
- 0.5mg twice daily if ≥70kg
- 0.5mg once daily if <70kg or intolerant to higher doses
- Continue for 3 months 1
Tapering:
- Decrease NSAID/aspirin doses gradually after symptom resolution and CRP normalization
- Ibuprofen: decrease by 200-400mg every 1-2 weeks 1
- Aspirin: decrease by 250-500mg every 1-2 weeks 1
Second-line therapy (only if contraindication/failure of first-line):
- Low-dose corticosteroids (prednisone 0.2-0.5mg/kg/day) 1
- Only after excluding infectious causes
- Maintain initial dose until symptoms resolve and CRP normalizes, then taper
2. Recurrent Pericarditis
Recurrence is defined as return of symptoms after a symptom-free interval of at least 4-6 weeks 1
First-line therapy:
Second-line therapy:
- Low-dose corticosteroids if NSAIDs and colchicine fail or are contraindicated 1
Third-line therapy (for multiple recurrences):
Fourth-line therapy:
- Pericardiectomy (last resort) 1
Special Considerations
Myopericarditis
- Hospitalization required for diagnosis and monitoring 1
- Coronary angiography recommended to rule out acute coronary syndromes 1
- CMR recommended to confirm myocardial involvement 1
- Rest and avoidance of physical activity for 6 months 1
- Anti-inflammatory therapy at lowest effective doses 1
Exercise Restrictions
- Non-athletes: Restrict until symptom resolution and normalization of CRP, ECG, and echocardiogram 1
- Athletes: Restrict for at least 3 months and until normalization of all parameters 1
Monitoring and Follow-up
- Use CRP to guide treatment duration and assess response 1
- Continue therapy until complete symptom resolution and CRP normalization 1
- Follow-up echocardiogram to assess for effusion resolution
- Monitor for complications (tamponade, constrictive pericarditis)
Complications and Prognosis
- Most patients with idiopathic/viral pericarditis have good long-term prognosis 1
- Recurrence rate: 15-30% without colchicine, reduced to about 16.7% with colchicine 1, 2
- Risk of constrictive pericarditis: <1% in idiopathic cases, higher (20-30%) in bacterial etiologies 1
- Cardiac tamponade is rare in idiopathic pericarditis but more common with specific etiologies like malignancy 1
Common Pitfalls to Avoid
Using corticosteroids as first-line therapy - This increases risk of recurrence and should be avoided unless specifically indicated 1
Inadequate treatment duration - Premature discontinuation before symptom and CRP normalization increases recurrence risk 1, 4
Insufficient colchicine duration - Should be continued for 3 months in first episode and 6 months in recurrences 1, 2
Failure to taper NSAIDs/aspirin - Abrupt discontinuation may lead to rebound symptoms 1
Excessive physical activity - Rest is important until inflammation resolves 1