What is the management of pericarditis?

Pericarditis: Presentation, Diagnosis, and Management

The first-line treatment for acute pericarditis consists of aspirin or NSAIDs (such as ibuprofen) combined with colchicine for at least 3 months, with gastroprotection. 1

Clinical Presentation

Acute pericarditis is diagnosed when at least 2 of the following 4 criteria are present:

• Pericarditic chest pain (typically sharp, pleuritic, and worsens when supine) - present in approximately 90% of cases 2
• Pericardial friction rub (auscultatory finding) - present in less than 30% of cases 2
• New widespread ST-segment elevation or PR depression on ECG - present in 25-50% of cases 2
• New or worsening pericardial effusion - present in approximately 60% of cases 2, 1

Additional supportive findings include:

• Elevated inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, white blood cell count) 1
• Evidence of pericardial inflammation on imaging (CT, CMR) 1

Diagnostic Approach

The following diagnostic tests are recommended for all patients with suspected pericarditis:

• ECG (Class I recommendation, Level C evidence) 1
• Transthoracic echocardiography (Class I recommendation, Level C evidence) 1
• Chest X-ray (Class I recommendation, Level C evidence) 1
• Assessment of inflammatory markers (CRP) and myocardial injury markers (troponin) (Class I recommendation, Level C evidence) 1

ECG Findings

• Widespread ST-segment elevation and PR depression are typical hallmark signs 1
• ECG changes reflect epicardial inflammation rather than pericardial inflammation 1
• ECG changes are present in up to 60% of cases 1

Imaging

• Chest X-ray is typically normal unless pericardial effusion exceeds 300 ml 1
• Echocardiography can detect pericardial effusions and assess for tamponade 1
• Advanced imaging (CT/CMR) may be used to confirm pericardial inflammation in atypical cases 1

Risk Stratification

Major risk factors for poor prognosis include:

• High fever (>38°C) 1
• Subacute course (symptoms developing over several days without clear-cut onset) 1
• Large pericardial effusion (>20 mm diastolic echo-free space) 1
• Cardiac tamponade 1
• Failure to respond to NSAIDs within 7 days 1

Triage approach:

• Low-risk patients: outpatient management with empiric anti-inflammatories 1
• Moderate/high-risk patients: hospital admission and etiology search 1

Management

First-Line Treatment

• Aspirin (750-1000 mg every 8 hours for 1-2 weeks, then taper) or ibuprofen (600 mg every 8 hours for 1-2 weeks, then taper) with gastroprotection (Class I recommendation, Level A evidence) 1
• Colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg for 3 months) as adjunct to aspirin/NSAIDs (Class I recommendation, Level A evidence) 1

Treatment Monitoring

• Serum CRP should be used to guide treatment duration and assess response (Class IIa recommendation, Level C evidence) 1
• Evaluate response to anti-inflammatory therapy after 1 week (Class I recommendation, Level B evidence) 1
• Treatment should continue until symptoms resolve and CRP normalizes 1

Second-Line Treatment

• Low-dose corticosteroids (0.2-0.5 mg/kg/day of prednisone) should be considered only when:
  • Aspirin/NSAIDs and colchicine are contraindicated or have failed
  • Infectious causes have been excluded
  • There is a specific indication such as autoimmune disease (Class IIa recommendation, Level C evidence) 1
• Corticosteroids are NOT recommended as first-line therapy (Class III recommendation, Level C evidence) 1

Activity Restrictions

• For non-athletes: restrict exercise until symptoms resolve and CRP, ECG, and echocardiogram normalize (Class IIa recommendation, Level C evidence) 1
• For athletes: restrict exercise for at least 3 months and until symptoms resolve and CRP, ECG, and echocardiogram normalize (Class IIa recommendation, Level C evidence) 1

Management of Recurrent Pericarditis

Recurrent pericarditis is defined as a documented first episode of acute pericarditis, a symptom-free interval of 4-6 weeks or longer, and evidence of subsequent recurrence 1.

• Continue colchicine for at least 6 months with the first recurrence 2
• For multiple recurrences, consider:
  • Longer colchicine courses
  • Azathioprine, IVIG, or anakinra (IL-1 receptor antagonist) for corticosteroid-dependent cases 1, 2

Tapering Corticosteroids (if used)

For patients requiring corticosteroids, follow this tapering schedule:

• 50 mg prednisone: decrease by 10 mg/day every 1-2 weeks

• 50-25 mg: decrease by 5-10 mg/day every 1-2 weeks
• 25-15 mg: decrease by 2.5 mg/day every 2-4 weeks
• <15 mg: decrease by 1.25-2.5 mg/day every 2-6 weeks 1

Special Considerations

Myopericarditis

• Rest and avoidance of physical activity beyond normal sedentary activities is recommended 1
• Athletes should avoid exercise for at least 6 months from illness onset 1
• Consider lower doses of NSAIDs compared to pure pericarditis 1

Purulent Pericarditis

• Requires urgent pericardiocentesis 1
• Intravenous antimicrobial therapy should be started empirically until microbiological results are available 1
• Consider subxiphoid pericardiostomy and rinsing of the pericardial cavity 1

Uraemic Pericarditis

• Consider intensifying dialysis in patients with adequate dialysis who develop pericarditis 1
• NSAIDs and corticosteroids may be considered when intensive dialysis is ineffective 1
• Colchicine is contraindicated in patients with severe renal impairment 1

Prognosis

• Most patients with acute idiopathic or viral pericarditis have a good long-term prognosis 1
• Cardiac tamponade is rare in idiopathic pericarditis but more common with specific etiologies (malignancy, TB, purulent pericarditis) 1
• Constrictive pericarditis occurs in <1% of patients with idiopathic pericarditis 1
• Recurrence rate is 15-30% after initial episode, but may increase to 50% after first recurrence in patients not treated with colchicine 1
• With appropriate treatment, 70-85% of patients have a benign course 2