What is the medical management of pericarditis?

Medical Management of Pericarditis

The first-line treatment for pericarditis is high-dose aspirin or NSAIDs plus colchicine, with treatment duration guided by symptom resolution and normalization of inflammatory markers. 1, 2

Diagnosis and Evaluation

Before initiating treatment, confirm the diagnosis with at least 2 of the following:

• Sharp, pleuritic chest pain that worsens when supine (present in ~90% of cases)
• New widespread ECG changes (ST-segment elevation and PR depression)
• New or increased pericardial effusion
• Pericardial friction rub

Additional evaluation should include:

• Inflammatory markers (CRP)
• Cardiac injury markers (troponin)
• Echocardiography to assess for effusion, tamponade, or constrictive physiology
• Chest X-ray (frontal and lateral views)

Risk Stratification

Determine if hospitalization is needed based on:

• High-risk features: fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, or immunosuppression
• Moderate-risk: failure to respond to NSAIDs after at least 1 week of therapy
• Low-risk: absence of the above factors (can be managed as outpatient)

Treatment Algorithm

1. First-Line Therapy (for acute pericarditis)

• NSAIDs/Aspirin:

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

• PLUS Colchicine:

  • 0.5 mg once daily (if <70 kg) or 0.5 mg twice daily (if ≥70 kg) for 3 months 1, 2
  • No loading dose required
  • Reduces recurrence risk from 30% to approximately 15-17% 3

• Activity Restriction:

  • Until symptoms resolve and CRP normalizes
  • For athletes, minimum 3 months restriction 1, 2

2. Second-Line Therapy (if contraindications or failure of first-line)

• Low-dose corticosteroids:
  • Prednisone 0.2-0.5 mg/kg/day (not 1.0 mg/kg/day)
  • Only after excluding infectious causes
  • Maintain until symptoms resolve and CRP normalizes, then taper slowly 1
  • Caution: corticosteroids increase risk of recurrence and chronicity 2

3. For Recurrent Pericarditis

• Continue/restart first-line therapy with longer duration
• Colchicine should be given for at least 6 months 3
• For multiple recurrences or steroid-dependent cases:
  • Consider IL-1 blockers (anakinra, rilonacept) 3, 4
  • Alternative options: azathioprine or intravenous immunoglobulins 4

Monitoring and Follow-up

• Weekly clinical evaluation during acute phase
• Serial CRP measurements to guide treatment duration
• Repeat echocardiography to monitor resolution
• Continue anti-inflammatory therapy until complete symptom resolution and CRP normalization

Important Considerations

• Etiology: In developed countries, 80-90% of cases are idiopathic/viral. In endemic areas, tuberculosis is the most common cause 3, 5
• Complications: Risk of constrictive pericarditis (<1% in idiopathic cases, 20-30% in bacterial cases) 1
• Recurrence risk: 15-30% without colchicine, reduced to 8-15% with colchicine 2, 5
• Avoid: High-dose corticosteroids as first-line therapy due to increased recurrence risk 1, 2

Special Situations

• Cardiac tamponade: Requires urgent pericardiocentesis with echocardiographic or fluoroscopic guidance 2
• Constrictive pericarditis: May require pericardiectomy, though transient forms may respond to anti-inflammatory therapy 1
• Tuberculous pericarditis: Requires specific antituberculous therapy 3, 5

Following this algorithm with appropriate anti-inflammatory therapy and colchicine leads to favorable outcomes in most patients, though vigilance for recurrence is necessary.