What are the treatment recommendations for acute pericarditis?

Treatment Recommendations for Acute Pericarditis

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

Diagnosis

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

• Pericarditic chest pain (typically sharp, pleuritic, improves with sitting forward)
• Pericardial friction rub on auscultation
• ECG changes (widespread ST elevations, PR depressions)
• New or worsening pericardial effusion

Risk Stratification

Before initiating treatment, patients should be stratified by risk:

High-risk features (require hospitalization):

• Fever >38°C (>100.4°F)
• Subacute onset (symptoms developing over several days)
• Large pericardial effusion (>20mm)
• Cardiac tamponade
• Failure to respond to NSAIDs within 7 days
• Immunosuppression
• History of trauma
• Oral anticoagulant therapy

Low-risk patients:

• Can be managed as outpatients if they respond to initial NSAID therapy
• No specific etiology suspected
• No predictors of poor prognosis

Treatment Algorithm

First-line therapy (Class I, Level A evidence) 1:

1. NSAIDs/Aspirin:

   • Aspirin: 750-1000mg every 8 hours (1.5-4g/day) for 1-2 weeks
   • OR Ibuprofen: 600mg every 8 hours (1800mg/day) for 1-2 weeks
   • Provide gastroprotection

2. PLUS Colchicine (mandatory adjunct):

   • Weight <70kg: 0.5mg once daily for 3 months
   • Weight ≥70kg: 0.5mg twice daily for 3 months

3. Tapering:

   • Aspirin: Decrease by 250-500mg every 1-2 weeks
   • Ibuprofen: Decrease by 200-400mg every 1-2 weeks
   • Colchicine tapering is not mandatory but may be considered in the last weeks

Second-line therapy (only if contraindications/failure of first-line) 1:

• Low-dose corticosteroids (prednisone 0.2-0.5mg/kg/day)
• Only after excluding infectious causes
• Must be combined with colchicine
• Maintain initial dose until symptoms resolve and CRP normalizes
• Very slow tapering to prevent recurrence

Monitoring and Follow-up

1. Use CRP to guide treatment duration (Class IIa recommendation) 1, 2

   • Continue treatment until symptoms resolve and CRP normalizes
   • Monitor for recurrence

2. Activity restrictions:

   • Non-athletes: Restrict physical activity until symptoms resolve and CRP, ECG, and echocardiogram normalize
   • Athletes: Restrict exercise for at least 3 months after symptoms resolve and tests normalize

Important Caveats

• Avoid corticosteroids as first-line therapy (Class III recommendation) 1

  • They increase risk of recurrence and chronicity
  • Use only when NSAIDs/colchicine contraindicated or failed

• Recurrence risk:

  • 15-30% without colchicine
  • Reduced to approximately 8-15% with colchicine 3
  • Risk factors for recurrence: inadequate initial treatment, early corticosteroid use

• Prognosis:

  • Most idiopathic/viral cases have excellent prognosis
  • Cardiac tamponade is rare in idiopathic cases (<3%) 4
  • Constrictive pericarditis occurs in <1% of idiopathic cases 1

Special Considerations

• Specific etiologies: When a specific cause is identified (TB, autoimmune, etc.), treat the underlying condition
• Pregnancy: NSAIDs may be used in first and second trimesters; corticosteroids may be considered after 20 weeks' gestation 5
• Refractory cases: Consider additional therapies like azathioprine, IVIG, or IL-1 blockers (anakinra) 6, 4

By following this evidence-based approach, most patients with acute pericarditis will have complete resolution of symptoms with minimal risk of complications or recurrence.