What are the admission criteria for pericarditis?

Admission Criteria for Pericarditis

Patients with pericarditis should be hospitalized if they have any major risk factors including fever >38°C, subacute course, large pericardial effusion, cardiac tamponade, or failure to respond to NSAIDs within 7 days. 1, 2

Risk Stratification Algorithm

High-Risk Patients (Require Admission)

• Presence of any major risk factors:

  • Fever >38°C (>100.4°F) 1, 3
  • Subacute course (symptoms developing over several days without clear-cut acute onset) 1
  • Large pericardial effusion (diastolic echo-free space >20 mm) 1, 2
  • Cardiac tamponade (hemodynamic compromise) 1, 4
  • Failure to respond to NSAIDs within 7 days 1

• Presence of minor risk factors:

  • Myopericarditis (elevated cardiac biomarkers indicating myocardial involvement) 1, 2
  • Immunosuppression 1
  • Trauma 1
  • Oral anticoagulant therapy 1

• Suspected specific etiology requiring targeted treatment:

  • Bacterial/purulent pericarditis 5
  • Neoplastic pericarditis 1, 2
  • Tuberculosis pericarditis (especially in endemic areas) 1
  • Autoimmune disease-associated pericarditis 1

Low-Risk Patients (Outpatient Management)

• Absence of all major and minor risk factors 1, 2
• Typical presentation with good response to initial anti-inflammatory therapy 1, 6
• No evidence of hemodynamic compromise 2
• No significant pericardial effusion 1, 2

Diagnostic Evaluation for Admitted Patients

• Complete blood count and inflammatory markers (CRP, ESR) 1, 2

• Cardiac biomarkers (troponin, CK) to assess for myocardial involvement 1, 2

• Comprehensive transthoracic echocardiography to evaluate:

  • Presence and size of pericardial effusion 1, 2
  • Signs of tamponade (right atrial/ventricular diastolic collapse, respiratory variation in mitral/tricuspid flow) 2, 4
  • Ventricular function 1

• Additional testing based on clinical suspicion:

  • Blood cultures if bacterial etiology suspected 5
  • Tuberculosis testing in endemic areas 1
  • Autoimmune markers if connective tissue disease suspected 1
  • Cardiac MRI to assess pericardial inflammation and myocardial involvement 7

Management Considerations

• Admitted patients should receive targeted therapy based on the underlying etiology 1

• For idiopathic/viral pericarditis:

  • NSAIDs remain first-line therapy (e.g., aspirin 1500-3000 mg/day or ibuprofen 1200-2400 mg/day) 1, 2
  • Colchicine should be added to reduce recurrence risk 1, 3
  • Corticosteroids should be reserved as second-line therapy when NSAIDs are contraindicated or ineffective 1, 3

• For specific etiologies:

  • Purulent pericarditis: urgent drainage and appropriate antibiotics 5
  • Neoplastic pericarditis: targeted oncologic therapy and consideration of pericardiocentesis 1
  • Autoimmune pericarditis: disease-specific immunosuppressive therapy 1

Common Pitfalls and Caveats

• Failure to recognize cardiac tamponade, which can rapidly progress to shock and death 4
• Underestimating the risk of recurrence (occurs in approximately 30% of patients) 3
• Premature use of corticosteroids, which may increase recurrence risk 7
• Inadequate follow-up after discharge (should be evaluated after 1 week to assess treatment response) 1
• Missing concomitant myocardial involvement, which may require different management approaches 1