From the Guidelines
Pericarditis should be managed with hospital admission for high-risk patients, and treatment should include colchicine as first-line therapy, in addition to aspirin or NSAIDs, for a duration of 3 months for acute pericarditis and 6 months for recurrent pericarditis, as recommended by the 2015 ESC guidelines 1. The initial investigations for pericarditis should include:
- ECG to show widespread ST elevation and PR depression
- Echocardiogram to assess for pericardial effusion
- Chest X-ray to evaluate for cardiomegaly
- Blood tests for inflammatory markers (ESR, CRP) and cardiac enzymes (troponin) The treatment approach should prioritize the use of colchicine, with a dose of 0.5 mg twice daily for patients >70 kg or 0.5 mg once daily for patients <70 kg, as an adjunct to aspirin or NSAIDs therapy 1. Corticosteroids are not recommended as first-line therapy for acute pericarditis, but may be considered for refractory cases or specific etiologies 1. CRP levels should be monitored to guide treatment duration and assess response to therapy, as recommended by the 2015 ESC guidelines 1. In cases of pericardial effusion, therapy should be targeted at the underlying cause, and pericardiocentesis with prolonged pericardial drainage may be considered for symptomatic effusions without evidence of inflammation 1. It is essential to treat the underlying cause of pericarditis, if identified, such as bacterial infections or autoimmune conditions, and to monitor patients for complications like cardiac tamponade or constrictive pericarditis. Rest and activity restriction, particularly avoiding competitive sports for at least 3 months after symptom resolution, is also crucial in the management of pericarditis.
From the Research
Investigations for Pericarditis
- Diagnosis of acute pericarditis is based on the presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine, new widespread electrocardiographic ST-segment elevation and PR depression, a new or increased pericardial effusion, or a pericardial friction rub 2
- Electrocardiography, echocardiography, and cardiac biomarkers are used to diagnose and assess the severity of pericarditis 2, 3
Treatment Options for Pericarditis
- Empiric anti-inflammatory therapy with aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) is the mainstay of treatment for acute and recurrent pericarditis 4, 2, 5, 3
- Colchicine is often used as an adjunct to NSAIDs to relieve symptoms and reduce the risk of recurrence 4, 2, 5, 3
- Corticosteroids are used as a second-line treatment for patients who do not respond to NSAIDs and colchicine, or for those with specific medical conditions such as autoimmune diseases or postpericardiotomy syndrome 4, 2, 5, 6
- Interleukin-1 blockers may be used as a third-line option for patients with recurrent pericarditis who cannot be weaned off corticosteroids or have contraindications to corticosteroids 5, 3
Management of Recurrent Pericarditis
- Patients with recurrent pericarditis may require long-term treatment with colchicine and/or corticosteroids 2, 5, 3
- A 3-month course of colchicine is recommended to reduce the risk of recurrence 2
- Corticosteroids may be used at low doses with gradual tapering to minimize the risk of recurrence and side effects 6
- Interleukin-1 blockers may be considered for patients with multiple recurrences who are refractory to conventional treatment 5, 3