What is the protocol for managing pericarditis?

Protocol for Managing Pericarditis

First-line treatment for pericarditis should consist of high-dose aspirin or NSAIDs plus colchicine, with treatment continued until complete symptom resolution and normalization of inflammatory markers. 1

Diagnosis

Acute pericarditis is diagnosed when at least 2 of the following are present:

• Sharp, pleuritic chest pain that worsens when supine (≈90%)
• New widespread ECG ST-segment elevation and PR depression (≈25%-50%)
• New or increased pericardial effusion (≈60%)
• Pericardial friction rub (<30%) 2

Initial Evaluation

• C-reactive protein (CRP) - to monitor disease activity
• Electrocardiogram (ECG) - to detect typical changes
• Echocardiogram - to assess for pericardial effusion
• Chest X-ray - to evaluate cardiac silhouette 1

Treatment Algorithm

First-Line Therapy

1. NSAIDs/Aspirin:

   • Aspirin: 500-1000 mg every 6-8 hours (1.5-4 g/day)
   • Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day)
   • Indomethacin: 25-50 mg every 8 hours 3

   PLUS

2. Colchicine:

   • 0.5 mg twice daily for patients ≥70 kg
   • 0.5 mg once daily for patients <70 kg 3, 1

Duration and Tapering

• Continue treatment until complete resolution of symptoms AND normalization of CRP
• Taper NSAIDs gradually:
  • Aspirin: Decrease by 250-500 mg every 1-2 weeks
  • Ibuprofen: Decrease by 200-400 mg every 1-2 weeks
  • Indomethacin: Decrease by 25 mg every 1-2 weeks 3
• Continue colchicine for at least 3-6 months regardless of symptom resolution 1

Second-Line Therapy (Corticosteroids)

Only use corticosteroids when:

• Incomplete response to aspirin/NSAIDs and colchicine
• Contraindications to NSAIDs exist
• Specific indications are present (systemic inflammatory diseases, post-pericardiotomy syndromes, pregnancy) 3, 1

Corticosteroid Protocol:

• Starting dose: Prednisone 0.2-0.5 mg/kg/day
• Tapering schedule:

  • 50 mg: Reduce by 10 mg/day every 1-2 weeks

  • 50-25 mg: Reduce by 5-10 mg/day every 1-2 weeks
  • 25-15 mg: Reduce by 2.5 mg/day every 2-4 weeks
  • <15 mg: Reduce by 1.25-2.5 mg/day every 2-6 weeks 3

Important: Corticosteroids are associated with higher recurrence rates (odds ratio 4.30) and should be avoided unless specifically indicated 1

Special Considerations

Myopericarditis

• Hospitalization is recommended for diagnosis and monitoring
• Coronary angiography should be performed to rule out acute coronary syndromes
• Cardiac MRI is recommended to confirm myocardial involvement
• Rest and avoidance of physical activity for 6 months 3

Specific Etiologies

1. Idiopathic/Viral Pericarditis:

   • Risk of constrictive pericarditis <1%
   • Treatment: NSAIDs/Aspirin and colchicine 1

2. Tuberculous Pericarditis:

   • Risk of constrictive pericarditis 20-30%
   • Treatment: Anti-tuberculosis therapy plus corticosteroids 1, 4

3. Bacterial Pericarditis:

   • Risk of constrictive pericarditis 20-30%
   • Treatment: Urgent pericardial drainage plus targeted antibiotics
   • Consider vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, and ciprofloxacin 400 mg/day 1, 4

Exercise Restriction

• 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
• For myopericarditis: Rest and avoidance of physical activity for 6 months 3

Follow-up

• Schedule visits every 1-2 months until treatment completion
• Monitor for:
  • Symptom resolution
  • CRP normalization
  • ECG changes resolution
  • Resolution of pericardial effusion (if present) 1

Management of Recurrent Pericarditis

• Continue colchicine for at least 6 months after first recurrence 2
• For multiple recurrences, consider IL-1 blockers as steroid-sparing therapy 2
• Failure to add colchicine doubles the risk of recurrence 1

Pitfalls to Avoid

1. Early discontinuation of colchicine (associated with higher recurrence rates)
2. Inappropriate use of corticosteroids (increases recurrence risk)
3. Inadequate tapering of anti-inflammatory medications
4. Resuming physical activity too early, especially in athletes or cases of myopericarditis
5. Not monitoring CRP to guide therapy duration and tapering