What are the clinical manifestations and treatment options for pericarditis?

Clinical Manifestations and Treatment of Pericarditis

Pericarditis presents with characteristic chest pain, pericardial friction rub, ECG changes, and possible pericardial effusion, and is best treated with a combination of NSAIDs and colchicine as first-line therapy. 1, 2

Clinical Manifestations

Diagnostic Criteria

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

1. Chest Pain (most common symptom):

   • Sharp, pleuritic, retrosternal pain
   • Often radiates to left shoulder
   • Typically improves when sitting up or leaning forward
   • May worsen with deep breathing or lying supine 1, 3

2. Pericardial Friction Rub:

   • Present in up to 85% of patients
   • Scratchy, grating sound best heard at left sternal border 3

3. ECG Changes (evolve through stages):

   • Widespread concave upward ST-segment elevation
   • PR segment depression
   • Absence of reciprocal T-wave inversions or Q waves 1, 3

4. Pericardial Effusion:

   • New or worsening effusion detected on echocardiography 1

Laboratory Findings

• Elevated inflammatory markers (CRP, ESR)
• Possible troponin elevation indicating myocardial involvement (myopericarditis)
• Leukocytosis may be present 1, 2

Associated Conditions

• Myopericarditis: When pericarditis has concomitant myocardial involvement
• Perimyocarditis: When myocarditis has pericardial involvement 1

Treatment Approach

First-Line Therapy

1. NSAIDs:

   • Ibuprofen: 600mg every 8 hours (1200-2400mg/day)
   • Aspirin: 750-1000mg every 8 hours (1500-4000mg/day) - preferred when antiplatelet therapy is required or in ischemic heart disease
   • Continue until complete symptom resolution and CRP normalization 1, 2

2. Colchicine (in addition to NSAIDs):

   • Weight-based dosing:
     • <70kg: 0.5mg once daily
     • ≥70kg: 0.5mg twice daily
   • Duration: 3 months for first episode, 6 months for recurrent cases
   • Reduces recurrence rates from 15-30% to 8-15% 1, 2

3. Exercise Restriction:

   • Until symptoms resolve and CRP normalizes 1

Second-Line Therapy

1. Corticosteroids:
   • Only when:
     • Contraindications to NSAIDs/colchicine exist
     • Infectious causes have been excluded
     • Incomplete response to first-line therapy
   • Starting dose: 0.25-0.50 mg/kg/day of prednisone
   • Careful tapering schedule required to avoid recurrence 1, 2

Tapering Protocol

1. NSAIDs: Decrease by 250-500mg every 1-2 weeks
2. Corticosteroids:

   • 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 1

Third-Line Therapy (for refractory cases)

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

Fourth-Line Therapy

• Pericardiectomy (as last resort) 1

Risk Stratification and Monitoring

High-Risk Features (requiring hospitalization)

• Fever >38°C
• Subacute course (symptoms developing over days/weeks)
• Large pericardial effusion (>20mm)
• Cardiac tamponade
• Failure to respond to NSAIDs
• Immunosuppression 1, 2

Monitoring

• Initial follow-up: 1-2 weeks after starting treatment
• Subsequent follow-up: Every 1-2 months until treatment completion
• Monitor:
  • Symptom resolution
  • CRP normalization
  • ECG changes resolution
  • Resolution of pericardial effusion (if present) 2

Special Considerations

Myopericarditis Management

• Similar to uncomplicated pericarditis
• Cardiac MRI useful for diagnosis
• Additional rest and exercise restriction recommended 1

Etiology-Specific Treatment

• Bacterial pericarditis: Drainage plus targeted antibiotics
• Tuberculous pericarditis: Anti-TB therapy plus corticosteroids
• Autoimmune causes: May require specific immunosuppressive therapy 1, 2

Common Pitfalls to Avoid

1. Overuse of corticosteroids - associated with higher recurrence rates
2. Inadequate duration of treatment - leads to recurrences
3. Failure to add colchicine - doubles recurrence risk
4. Missing high-risk features requiring hospitalization
5. Inadequate monitoring of treatment response 1, 2, 4

By following this structured approach to diagnosis and treatment, most patients with pericarditis can be effectively managed with good outcomes and reduced risk of recurrence.