Is a beta blocker (beta-adrenergic blocking agent) suitable for treating pericarditis?

Beta Blockers in Pericarditis Management

Beta blockers are not recommended as standard therapy for pericarditis and are not included in guideline-directed treatment protocols for this condition. 1, 2

Standard Treatment for Pericarditis

The cornerstone treatments for pericarditis according to European Society of Cardiology (ESC) guidelines include:

1. First-line therapy:

   • NSAIDs/Aspirin at high doses (Class I, Level A recommendation)
     • Aspirin: 1500-3000 mg/day
     • Ibuprofen: 1200-2400 mg/day
     • Indomethacin: 75-150 mg/day
   • Colchicine (0.5mg twice daily for patients ≥70kg or 0.5mg daily for patients <70kg) for 3-6 months (Class I, Level A) 2

2. Second-line therapy:

   • Low-dose corticosteroids (0.25-0.50 mg/kg/day) when NSAIDs/colchicine are contraindicated or ineffective (Class III, Level B for first-line use) 1, 2

3. Third-line therapy:

   • IL-1 blockers (anakinra, rilonacept) for corticosteroid-dependent recurrent pericarditis 2, 3

Beta Blockers in Pericarditis

While beta blockers are not part of standard guideline recommendations for pericarditis, there is limited evidence suggesting potential benefits in specific circumstances:

• A 2021 study found that beta blockers added to standard anti-inflammatory therapy in patients with pericarditis who had heart rates >75 bpm and symptoms (chest pain and palpitations) showed:
  • Reduced persistence of symptoms at 3 weeks (4% vs 14%, p=0.024)
  • A trend toward reduced recurrences at 18 months 4

This suggests beta blockers might help control symptoms in selected patients, particularly those with tachycardia, by:

1. Reducing heart rate, which may decrease mechanical irritation of the inflamed pericardium
2. Potentially limiting "mechanical inflammation" 5

Important Considerations and Caveats

• Beta blockers should not replace standard anti-inflammatory therapy but might be considered as adjunctive treatment in specific cases with tachycardia and persistent symptoms 4
• In myopericarditis (pericarditis with myocardial involvement), some authors recommend reducing NSAID dosages compared to pure pericarditis due to concerns about potential adverse effects on myocardial healing 1
• Rest and avoidance of physical activity are recommended for all patients with myopericarditis, with exercise restriction for at least 6 months from illness onset in cases of myocardial involvement 1

Practical Approach

1. Start with guideline-directed therapy:

   • NSAIDs/Aspirin + Colchicine as first-line treatment
   • Monitor CRP levels to guide treatment duration
   • Taper medications gradually after symptom resolution and CRP normalization

2. Consider beta blockers only as adjunctive therapy if:

   • Patient has persistent symptoms despite standard treatment
   • Heart rate is elevated (>75 bpm)
   • No contraindications to beta blockers exist

3. Monitor response to therapy with:

   • Symptom assessment
   • CRP levels
   • ECG changes
   • Echocardiographic findings

Beta blockers should not be considered a primary treatment for pericarditis but may have a role in symptom management for selected patients with tachycardia as an adjunct to standard anti-inflammatory therapy.