What are the symptoms and treatment options for pericarditis?

Symptoms and Treatment of Pericarditis

Symptoms of Pericarditis

The classic presentation of pericarditis includes retrosternal or left precordial chest pain that radiates to the trapezius ridge, is pleuritic in nature, and varies with posture. 1

Key Clinical Manifestations:

• Sharp, pleuritic chest pain that worsens when lying supine and improves when sitting forward (present in approximately 90% of cases) 2
• Shortness of breath, especially when lying flat 1
• Fever, malaise, and myalgia often precede other symptoms, though elderly patients may not develop fever 1
• Pericardial friction rub on auscultation (mono-, bi-, or triphasic) - highly specific but transient, reported in 18-84% of patients 3, 1

Diagnostic Findings:

• ECG changes: widespread ST-segment elevation and PR depression (present in 25-50% of cases) 2, 1
• New or worsening pericardial effusion (present in approximately 60% of cases) 2
• Elevated inflammatory markers (CRP, ESR, white blood cell count) 1
• Elevated cardiac biomarkers (troponins I and T, CK-MB) may indicate associated myocardial involvement (perimyocarditis) 1

Diagnosis of Pericarditis

Diagnosis of acute pericarditis requires at least two of the following criteria: characteristic chest pain, pericardial friction rub, typical ECG changes, or new/worsening pericardial effusion. 3, 1

First-Level Diagnostic Workup (recommended for all cases):

• Complete blood count, renal and liver function tests, thyroid function 1
• Cardiac biomarkers (troponins, CK) 1
• ECG 1
• Transthoracic echocardiography 1
• Chest X-ray 1

Second-Level Diagnostic Workup (if first level is insufficient):

• CT and/or cardiac MRI 1
• Pericardiocentesis or surgical drainage if: cardiac tamponade is present, bacterial or neoplastic pericarditis is suspected, or moderate to large effusions are not responding to medical therapy 1

Treatment of Pericarditis

First-Line Treatment:

• NSAIDs are the cornerstone of treatment for acute pericarditis, with aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) recommended for 1-2 weeks with gastroprotection. 4, 1
• Colchicine should be added to NSAIDs as part of first-line therapy (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months to reduce risk of recurrence 4, 1
• Treatment duration should be guided by symptom resolution and normalization of CRP 4, 1
• Medication tapering should be gradual, decreasing doses over time (e.g., aspirin by 250-500 mg every 1-2 weeks) 4

Second-Line Treatment:

• Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be considered only when:
  • NSAIDs/colchicine are contraindicated
  • First-line therapy has failed
  • Infectious causes have been excluded 4, 1
• Corticosteroids are NOT recommended as first-line therapy due to risk of promoting chronicity and recurrences 4, 1

Management of Recurrent Pericarditis:

• First-line: Aspirin/NSAIDs plus colchicine and exercise restriction 1
• Second-line: Low-dose corticosteroids (after excluding infectious causes) 1
• Third-line: Immunoglobulin, anakinra, or azathioprine for refractory cases 1
• Fourth-line: Pericardiectomy as a last resort 1

Special Considerations

Activity Restrictions:

• Exercise restriction is recommended until symptoms resolve and CRP, ECG, and echocardiogram normalize 4, 1
• For athletes, exercise restriction should last at least 3 months 4, 1

Specific Etiologies:

• Tuberculous pericarditis: Anti-tuberculosis treatment with possible adjunctive corticosteroids 1
• Purulent pericarditis: Aggressive intravenous antimicrobial therapy and drainage (surgical or percutaneous) 1
• Uremic pericarditis: Intensification of dialysis; NSAIDs and corticosteroids may be considered if dialysis is ineffective 1

Common Pitfalls and Caveats

• Inadequate treatment of the initial episode is a common cause of recurrence 4
• Corticosteroids provide rapid symptom control but may increase risk of chronicity and recurrence 4
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 4, 2
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, intermediate (2-5%) for autoimmune/neoplastic, and high (20-30%) for bacterial causes 4
• Cardiac tamponade rarely occurs in idiopathic pericarditis but is more common with specific etiologies like malignancy or purulent pericarditis 4, 5