What is the treatment for pericarditis?

Treatment for Pericarditis

The first-line treatment for pericarditis consists of aspirin or NSAIDs combined with colchicine, with treatment duration guided by symptom resolution and CRP normalization. 1, 2

Diagnostic Approach

Diagnosis of pericarditis requires at least 2 of the following 4 criteria:

• Pericardial chest pain
• Pericardial friction rub
• ECG changes (widespread ST elevation or PR depression)
• New or worsening pericardial effusion

Risk Stratification

Patients should be classified into risk categories to determine management:

High-risk features (require hospitalization):

• Fever >38°C
• Subacute onset (symptoms developing over days)
• Large pericardial effusion (>20mm)
• Cardiac tamponade
• Failure to respond to NSAIDs within 7 days
• Immunosuppression
• Trauma
• Oral anticoagulant therapy
• Suspected non-viral etiology

Low-risk patients:

• Can be managed as outpatients if they respond to initial NSAID therapy
• No high-risk features present

Treatment Algorithm

First-line Treatment

1. NSAIDs:

   • Ibuprofen: 600mg every 8 hours (1200-2400mg/day) for 1-2 weeks, then taper by 200-400mg every 1-2 weeks
   • OR Aspirin: 750-1000mg every 8 hours (1.5-4g/day) for 1-2 weeks, then taper by 250-500mg every 1-2 weeks
   • Provide gastroprotection

2. Plus Colchicine:

   • 0.5mg once daily for patients <70kg
   • 0.5mg twice daily for patients ≥70kg
   • Continue for 3 months in acute pericarditis
   • Continue for at least 6 months in recurrent pericarditis

3. Activity Restriction:

   • Non-athletes: Until symptom resolution and normalization of CRP, ECG, and echocardiogram
   • Athletes: Minimum 3 months after symptom resolution and test normalization

Second-line Treatment (if first-line fails or is contraindicated)

1. Low-dose corticosteroids:
   • Only after excluding infectious causes
   • Prednisone 0.2-0.5mg/kg/day
   • Slow tapering:

     • 50mg: reduce by 10mg/day every 1-2 weeks

     • 50-25mg: reduce by 5-10mg/day every 1-2 weeks
     • 25-15mg: reduce by 2.5mg/day every 2-4 weeks
     • <15mg: reduce by 1.25-2.5mg/day every 2-6 weeks

Third-line Treatment (for refractory recurrent cases)

• Intravenous immunoglobulin
• Anakinra (IL-1 receptor antagonist)
• Azathioprine

Fourth-line Treatment

• Pericardiectomy (last resort after thorough trial of medical therapy)

Special Considerations

Bacterial Pericarditis

• Requires urgent drainage and targeted antibiotics
• High mortality if untreated (40% even with treatment)
• Consider vancomycin, ceftriaxone, and ciprofloxacin until culture results

Tuberculous Pericarditis

• Requires specific anti-TB therapy (isoniazid, rifampin, pyrazinamide, ethambutol)
• Consider adjunctive corticosteroids

Monitoring and Follow-up

• Use CRP to guide treatment duration and response
• Taper medications only after symptoms resolve and CRP normalizes
• When tapering, remove one drug at a time
• Monitor for recurrences (15-30% without colchicine, reduced to ~15% with colchicine)

Prognosis

• Most cases of idiopathic/viral pericarditis have excellent long-term prognosis
• Risk of constrictive pericarditis is <1% in viral/idiopathic cases
• Cardiac tamponade is rare in idiopathic cases
• Prognosis is related to etiology rather than number of recurrences

Common Pitfalls to Avoid

1. Using corticosteroids as first-line therapy (increases risk of recurrence and chronicity)
2. Failing to add colchicine to NSAIDs (doubles recurrence risk)
3. Tapering medications too quickly
4. Not monitoring CRP to guide treatment duration
5. Inadequate initial anti-inflammatory dosing (needs to be every 8 hours)
6. Not considering specific etiologies in high-risk patients

Following this evidence-based approach will optimize outcomes by reducing symptom duration, preventing complications, and minimizing recurrence rates.