Initial Workup and Treatment for Pericarditis
The initial workup for pericarditis requires at least 2 of 4 diagnostic criteria (chest pain, pericardial friction rub, ECG changes, and pericardial effusion), and first-line treatment consists of NSAIDs (ibuprofen 600 mg every 8 hours) or aspirin (750-1000 mg every 8 hours) plus colchicine (0.5 mg twice daily for patients ≥70 kg or 0.5 mg once daily for patients <70 kg) until symptom resolution and CRP normalization. 1
Diagnostic Workup
Essential Diagnostic Tests:
- C-reactive protein (CRP): To monitor disease activity and guide treatment duration 1
- Electrocardiogram (ECG): To detect typical changes of pericarditis (widespread concave upward ST-segment elevation, PR segment depression) 1
- Echocardiogram: To assess for pericardial effusion and rule out tamponade 1
- Chest X-ray: To evaluate cardiac silhouette and rule out other pulmonary pathology 1
- Troponin levels: To identify myocardial involvement (myopericarditis) 1
Diagnostic Criteria:
Diagnosis requires at least 2 of the following 4 criteria:
- Characteristic chest pain (sharp, pleuritic, improves with sitting forward)
- Pericardial friction rub (present in <30% of cases) 2
- ECG changes (widespread ST elevation, PR depression)
- New or worsening pericardial effusion 1
Treatment Algorithm
First-Line Treatment:
NSAIDs/Aspirin (with gastroprotection) 3, 1
- Ibuprofen: 600 mg every 8 hours (preferred due to favorable side effect profile)
- Aspirin: 750-1000 mg every 8 hours (preferred when antiplatelet therapy is required or ischemic heart disease is a concern)
- Continue until complete symptom resolution and CRP normalization
Colchicine (add to NSAIDs/Aspirin) 3, 1
- 0.5 mg twice daily for patients ≥70 kg
- 0.5 mg once daily for patients <70 kg or those intolerant to higher doses
- Continue for at least 3 months for first episode (reduces recurrence from 37.5% to 16.7%) 4
Second-Line Treatment (for refractory cases):
- Corticosteroids: Low to moderate doses (prednisone 0.2-0.5 mg/kg/day) 1
Treatment Duration:
- Continue treatment until symptoms resolve and CRP normalizes 3, 1
- Gradual tapering of therapies after CRP normalization, stopping one drug class at a time 3
Special Considerations
Etiology-Specific Management:
- Idiopathic/viral pericarditis: Most common in developed countries; treat with NSAIDs and colchicine 1
- Tuberculous pericarditis: Requires anti-tuberculosis therapy plus corticosteroids 1
- Bacterial pericarditis: Requires urgent drainage plus targeted antibiotics 1
Activity Restrictions:
- Non-athletes: Consider exercise restriction until symptom resolution and CRP normalization 3
- Athletes: Restrict exercise for at least 3 months after normalization of symptoms, CRP, ECG, and echocardiogram 3, 1
Monitoring and Follow-up
- Initial follow-up 1-2 weeks after starting treatment 1
- Subsequent follow-up every 1-2 months until treatment completion 1
- Monitor:
Prognosis and Complications
- Most patients with idiopathic/viral pericarditis have a good long-term prognosis 1
- Recurrence rate: 15-30% without colchicine, reduced to 8-15% with colchicine 1, 4
- Risk of constrictive pericarditis: <1% in idiopathic/viral cases 3, 1
- Cardiac tamponade is rare in idiopathic pericarditis but more common with specific etiologies (malignancy, TB) 1
Common Pitfalls to Avoid
- Premature discontinuation of therapy: Continue treatment until both symptoms resolve AND CRP normalizes 3, 1
- Corticosteroid use as first-line: Avoid unless specifically indicated, as they increase recurrence risk 3, 1
- Inadequate dosing: NSAIDs should be given at full anti-inflammatory doses every 8 hours until symptoms resolve 3, 1
- Failure to add colchicine: Adding colchicine significantly reduces recurrence rates and improves quality of life 4
- Missing myocardial involvement: Always check troponin levels to identify myopericarditis 1