What is the initial workup and treatment for suspected pericarditis?

Initial Workup and Treatment for Suspected Pericarditis

The initial workup for suspected pericarditis must include auscultation, ECG, transthoracic echocardiography, chest X-ray, and routine blood tests including inflammatory markers, complete blood count, renal/liver function tests, and cardiac biomarkers. 1

Diagnostic Workup

First-Level Investigations (Required for All Cases)

• Clinical Assessment

  • Auscultation for pericardial friction rub (present in <30% of cases)
  • Assessment for pleuritic chest pain that worsens when supine (present in ~90%)

• Laboratory Tests

  • Complete blood count
  • Renal function and liver tests
  • Thyroid function
  • Inflammatory markers (CRP and/or ESR)
  • Cardiac biomarkers (troponins, CK)

• Imaging and Other Tests

  • ECG (look for widespread ST-segment elevation and PR depression, present in 25-50%)
  • Transthoracic echocardiography (to assess for pericardial effusion, present in ~60%)
  • Chest X-ray

Second-Level Investigations (If First Level Not Sufficient)

• CT and/or cardiac MRI
• Pericardiocentesis or surgical drainage in cases of:
  • Cardiac tamponade
  • Suspected bacterial or neoplastic pericarditis
  • Symptomatic moderate to large effusions not responding to medical therapy

Risk Stratification

High-Risk Factors (Requiring More Extensive Workup)

• Fever >38°C
• Subacute course (symptoms developing over several days or weeks)
• Large pericardial effusion (diastolic echo-free space >20 mm)
• Cardiac tamponade
• Failure to respond to aspirin or NSAIDs

Treatment Approach

First-Line Therapy

• NSAIDs plus Colchicine 2
  • NSAIDs options:
    • Aspirin 500-1000 mg every 6-8 hours
    • Ibuprofen 600 mg every 8 hours
  • Colchicine:
    • 0.5 mg twice daily for patients ≥70 kg
    • 0.5 mg once daily for patients <70 kg
  • Continue until complete symptom resolution and normalization of CRP
  • Exercise restriction for at least 3-6 months

Second-Line Therapy (For Incomplete Response or Contraindications)

• Corticosteroids (prednisone 0.2-0.5 mg/kg/day) 2
  • Should be added to NSAIDs/colchicine as triple therapy when possible
  • 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
  • Critical threshold for recurrences at 10-15 mg/day

Important Considerations

• Before Starting Steroids: Exclude bacterial infections and TB
• Steroid Side-Effect Prevention:
  • Calcium supplementation (1,200-1,500 mg/day)
  • Vitamin D (800-1000 IU/day)
  • Consider bisphosphonates for men ≥50 years and postmenopausal women when prednisone ≥5.0-7.5 mg/day

Treatment Duration and Follow-up

• Continue treatment until complete resolution of symptoms and normalization of inflammatory markers
• Gradual tapering after CRP normalization
• Stop one drug class at a time (NSAIDs first, continue colchicine)
• Continue colchicine for at least 3-6 months regardless of symptom resolution 2
• Follow-up visits every 1-2 months until treatment completion

Etiology-Specific Considerations

• Idiopathic/Viral (most common in developed countries): NSAIDs/Aspirin + colchicine; risk of constrictive pericarditis <1% 3
• Tuberculous: Anti-tuberculosis therapy + corticosteroids; risk of constrictive pericarditis 20-30% 2
• Bacterial: Urgent drainage + targeted antibiotics; risk of constrictive pericarditis 20-30% 2
• Neoplastic/Autoimmune: Treatment of underlying condition; risk of constrictive pericarditis 2-5% 2

Common Pitfalls to Avoid

• Premature discontinuation of colchicine (associated with higher recurrence rates)
• Using corticosteroids as first-line therapy (increases risk of recurrence)
• Failing to exclude infections before starting steroids
• Not recognizing high-risk features requiring more extensive workup
• Overlooking specific etiologies requiring targeted treatment

Remember that with appropriate treatment, 70-85% of patients with pericarditis have a benign course, but early recognition and proper management are essential to prevent complications such as recurrence, tamponade, or constrictive pericarditis 3.