Management of Pericarditis
The management of pericarditis should primarily consist of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin as first-line therapy, combined with colchicine for at least 3-6 months to reduce recurrence risk. 1, 2
Diagnosis
Before initiating treatment, confirm diagnosis with at least 2 of the following:
- Sharp, pleuritic chest pain that worsens when supine (present in ~90% of cases)
- New widespread ST-segment elevation and PR depression on ECG (present in 25-50%)
- New or worsening pericardial effusion (present in ~60%)
- Pericardial friction rub (present in <30%)
Initial Workup
- ECG
- Transthoracic echocardiography
- Chest X-ray
- Laboratory tests:
- Inflammatory markers (CRP, ESR)
- Complete blood count
- Renal and liver function tests
- Cardiac biomarkers (troponin, CK)
Treatment Algorithm
First-Line Therapy
NSAIDs/Aspirin (high dose):
- Aspirin: 1500-3000 mg/day in 3-4 divided doses
- Ibuprofen: 1200-2400 mg/day in 3-4 divided doses
- Indomethacin: 75-150 mg/day in 3 divided doses
- Always provide gastric protection
Add Colchicine:
- Weight ≥70 kg: 0.5 mg twice daily
- Weight <70 kg: 0.5 mg once daily
- Duration: Minimum 3 months for first episode, 6 months for recurrent episodes
Second-Line Therapy (if first-line fails or is contraindicated)
- Low-dose corticosteroids:
- Prednisone 0.25-0.50 mg/kg/day
- Strict 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
Third-Line Therapy (for multiple recurrences)
- IL-1 blockers:
- Anakinra: 2 mg/kg/day up to 100 mg subcutaneously for at least 6 months, then taper
- Rilonacept: Loading dose of 320 mg SC followed by 160 mg weekly
Treatment Duration and Monitoring
- Continue treatment until complete symptom resolution AND CRP normalization
- Taper medications gradually:
- First taper NSAIDs/aspirin
- Maintain colchicine for the full recommended duration
- Monitor CRP levels regularly to guide treatment duration
- Follow-up echocardiography to assess resolution of effusion
Special Considerations
Hospitalization Criteria
Hospitalize patients with any of these high-risk features:
- Temperature >38°C (>100.4°F)
- Subacute onset
- Large pericardial effusion or tamponade
- Failure to respond to NSAIDs
- Suspected bacterial or tuberculous etiology
- Immunosuppressed state
Etiology-Specific Management
- Idiopathic/Viral: NSAIDs + colchicine (standard approach)
- Tuberculous: Anti-tuberculosis therapy + corticosteroids
- Bacterial: Urgent drainage + targeted antibiotics (e.g., vancomycin 1g twice daily, ceftriaxone 1-2g twice daily)
- Neoplastic/Autoimmune: Treat underlying condition
Activity Restrictions
- Rest and avoid physical activity beyond normal sedentary activities
- For isolated pericarditis: Return to exercise when no evidence of active disease
- For myopericarditis: Avoid physical exercise for at least 6 months
Prognosis
- Most cases (70-85%) have a benign course with appropriate treatment
- Recurrence rates: 15-30% without colchicine, reduced to 8-15% with colchicine
- Serious complications are rare in idiopathic cases:
- Constrictive pericarditis (<1%)
- Cardiac tamponade (<3%)
Common Pitfalls to Avoid
- Inadequate initial dosing: Use full anti-inflammatory doses of NSAIDs/aspirin
- Premature discontinuation: Continue treatment until CRP normalizes
- Rapid steroid tapering: Follow strict tapering schedule to prevent recurrence
- Omitting colchicine: Essential for reducing recurrence risk
- Missing high-risk features: Promptly identify patients requiring hospitalization
- Overlooking specific etiologies: Consider tuberculosis in endemic areas
Remember that while most cases are idiopathic or viral in developed countries, tuberculosis remains the most common cause in endemic areas and requires specific treatment.