What is the initial management for pericarditis?

Initial Management of Acute Pericarditis

The first-line treatment for acute pericarditis consists of high-dose NSAIDs/aspirin plus colchicine for 3-6 months, with outpatient management for low-risk patients and follow-up evaluation after one week. 1

Diagnostic Criteria

Acute pericarditis is diagnosed when 2 or more of the following are present:

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

Initial Evaluation

• Laboratory tests: Complete blood count, renal/liver function, thyroid function, inflammatory markers (CRP and/or ESR), and cardiac biomarkers (troponins, CK) 1
• Imaging: ECG, transthoracic echocardiography, chest X-ray 1
• Consider hospitalization for high-risk features or diagnostic uncertainty 1

Treatment Algorithm

Step 1: First-Line Therapy

• High-dose NSAIDs/aspirin plus colchicine
  • NSAIDs at anti-inflammatory doses given every 8 hours until symptom resolution and CRP normalization 1, 3
  • Colchicine for at least 3-6 months to reduce recurrence risk (reduces recurrence from 37.5% to 16.7%) 1, 2
  • Continue treatment until complete symptom resolution and normalization of inflammatory markers 1

Step 2: Activity Restriction

• Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes
• Minimum restriction period:
  • Athletes: 3 months after initial onset
  • Non-athletes: Until remission of symptoms 1

Step 3: Treatment of Underlying Causes

• Identify and treat specific etiologies (e.g., tuberculosis, bacterial infection, autoimmune disease) 1
• In tuberculosis-endemic areas, consider antitubercular therapy 2

Step 4: Second-Line Therapy (if needed)

• Corticosteroids when NSAIDs/colchicine are contraindicated or ineffective 1
• Caution: Corticosteroids are associated with higher risk of recurrence and should not be first-line therapy 1, 3
• If corticosteroids are necessary, follow recommended tapering protocol:

  • 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 1

Special Considerations

Medication Selection

• For uncomplicated acute pericarditis: NSAIDs/aspirin + colchicine 1, 4
• For pericarditis after myocardial infarction: Aspirin should replace other NSAIDs 4
• For recurrent pericarditis: Continue colchicine for at least 6 months 2
• For multiple recurrences: Consider IL-1 blockers (anakinra, rilonacept) as third-line therapy or second-line if corticosteroids are contraindicated 5, 6

Special Populations

• Children: Avoid aspirin due to risk of Reye's syndrome
  • Colchicine dosing: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses 1
• Pregnancy:
  • Low-moderate dose aspirin preferred during first and second trimesters
  • NSAIDs may be used until gestational week 20
  • All NSAIDs except low-dose aspirin must be withdrawn by gestational week 32
  • Prednisone at lowest effective doses may be used throughout pregnancy with calcium and vitamin D supplementation 1

Monitoring and Follow-up

• Track CRP levels to guide treatment duration
• Assess symptom resolution
• Follow ECG changes and echocardiogram findings
• Begin tapering only after CRP normalization and symptom resolution
• Taper gradually, removing one medication class at a time, starting with NSAIDs/aspirin while maintaining colchicine for the full duration
• Repeat echocardiogram if symptoms worsen or new symptoms develop 1

Common Pitfalls to Avoid

• Premature discontinuation of therapy before complete resolution of symptoms and normalization of inflammatory markers
• Rapid tapering of medications (within 1 month), which increases recurrence risk 5
• Using corticosteroids as first-line therapy, which is associated with higher recurrence rates 1, 3
• Failure to add colchicine to initial therapy, which significantly reduces recurrence risk 2, 6
• Overlooking underlying causes that require specific treatment 1