What is the initial management for pericarditis?

Initial Management of Pericarditis

The initial management for pericarditis should consist of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin as first-line treatment, with the addition of colchicine to improve symptoms and reduce recurrence risk. 1

Diagnosis and Initial 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) 2
• ECG changes: widespread concave upward ST-segment elevation, PR segment depression, and absence of reciprocal changes (present in 25-50% of cases) 1, 2
• New or increased pericardial effusion (present in ~60% of cases) 2
• Pericardial friction rub (present in <30% of cases) 2

Initial workup should include:

• C-reactive protein (CRP) to monitor disease activity and guide treatment duration
• Electrocardiogram (ECG)
• Echocardiogram to assess for pericardial effusion and rule out tamponade
• Chest X-ray to evaluate cardiac silhouette and rule out other pathology 1

First-Line Treatment

1. NSAIDs or Aspirin:

   • Provide full anti-inflammatory doses every 8 hours until symptom resolution 1, 3
   • Aspirin (750-1000 mg every 8 hours) is preferred in post-myocardial infarction settings due to its antiplatelet effects 1, 3
   • For other cases, ibuprofen or other NSAIDs can be used at full anti-inflammatory doses 4

2. Colchicine:

   • Add to NSAIDs/aspirin as part of first-line therapy, particularly in severely symptomatic cases 4
   • Reduces recurrence rates from 15-30% to approximately 8-15% 1
   • Standard course is 3 months for initial episode 2
   • For recurrent episodes, extend to at least 6 months 2

Treatment Duration and Monitoring

• Continue treatment until:

  • Complete resolution of symptoms
  • Normalization of inflammatory markers (CRP)
  • Resolution of ECG changes
  • Resolution of pericardial effusion (if present) 1

• Follow-up schedule:

  • Initial follow-up 1-2 weeks after starting treatment
  • Then every 1-2 months until treatment completion 1

Common Pitfalls to Avoid

1. Inadequate NSAID dosing: Use full anti-inflammatory doses given every 8 hours until symptoms resolve 1

2. Premature treatment discontinuation: This is a leading cause of recurrence; continue treatment until both symptoms and inflammatory markers normalize 1

3. Early corticosteroid use: Corticosteroids are not recommended as first-line therapy due to higher recurrence rates 1, 5

4. Failure to recognize high-risk patients: Women, those with PR-segment depression on ECG, and patients with secondary causes of pericarditis are more likely to fail NSAID therapy and require corticosteroids 5

Second-Line Treatment

If first-line treatment fails or is contraindicated:

• Corticosteroids:

  • Use low to moderate doses (prednisone 0.2-0.5 mg/kg/day)
  • Taper slowly to avoid recurrence 1
  • Be aware that corticosteroid use increases recurrence risk compared to NSAIDs alone 5

• Immunosuppressive agents (for multiple recurrences):

  • Options include azathioprine, methotrexate, or mycophenolate mofetil 6
  • IL-1 blockers have demonstrated efficacy in patients with multiple recurrences and may be preferred to corticosteroids in certain cases 2

Special Considerations

• Activity restrictions:

  • Non-athletes: Restrict exercise until symptom resolution and CRP normalization
  • Athletes: Restrict exercise for at least 3 months after normalization of symptoms, CRP, ECG, and echocardiogram 1

• Etiology-specific treatment:

  • Tuberculous pericarditis: Anti-tuberculosis therapy plus corticosteroids
  • Bacterial pericarditis: Urgent drainage plus targeted antibiotics
  • Neoplastic pericarditis: Treatment of underlying cancer
  • Uremic pericarditis: Treatment of underlying renal failure 1

• Dose adjustment:

  • Modify doses in patients with renal or hepatic impairment 1