What is the management of pericarditis?

Management of Pericarditis

The first-line treatment for acute pericarditis is aspirin or NSAIDs combined with colchicine for at least 3 months, with treatment duration guided by symptom resolution and normalization of inflammatory markers. 1

Diagnosis

• Diagnosis requires at least 2 of the following: pleuritic chest pain, pericardial friction rub, widespread ST-segment elevation/PR depression on ECG, or new/worsening pericardial effusion 1
• ECG, transthoracic echocardiography, and chest X-ray are recommended in all patients with suspected pericarditis (Class I recommendation) 2
• Assessment of inflammatory markers (CRP) and myocardial injury markers (troponin) is essential for diagnosis and monitoring treatment response 2

Risk Stratification

• Low-risk patients can be managed as outpatients with empiric anti-inflammatory therapy and follow-up after 1 week 2
• Major risk factors requiring hospitalization include:
  • High fever (>38°C)
  • Subacute onset (symptoms developing over days)
  • Large pericardial effusion (>20mm)
  • Cardiac tamponade
  • Failure to respond to NSAIDs within 7 days 1
• Minor risk factors include myopericarditis, immunosuppression, trauma, and oral anticoagulant therapy 2

First-Line Treatment

• NSAIDs (with gastroprotection):
  • Aspirin: 750-1000 mg every 8 hours for 1-2 weeks, then taper 1, 3
  • Ibuprofen: 600 mg every 8 hours for 1-2 weeks, then taper 3
• Colchicine (reduces recurrence rate from 37.5% to 16.7%):
  • 0.5 mg twice daily if ≥70 kg or 0.5 mg once daily if <70 kg 3, 4
  • Continue for at least 3 months in first episode and 6 months for recurrences 1, 4
• Monitor CRP to guide treatment duration - continue therapy until normalization 1

Second-Line Treatment

• Corticosteroids should NOT be used as first-line therapy as they increase risk of recurrence 3
• Consider low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) only when:
  • Infectious causes have been excluded
  • NSAIDs and colchicine are contraindicated or ineffective
  • Autoimmune disease is present 1, 3
• For multiple recurrences, interleukin-1 blockers have demonstrated efficacy and may be preferred over long-term corticosteroids 4

Management of Specific Types of Pericarditis

• Purulent pericarditis:
  • Requires urgent pericardiocentesis for diagnosis and drainage 2
  • Intravenous antimicrobial therapy based on culture results 2
  • Consider subxiphoid pericardiostomy and pericardial cavity rinsing for loculated effusions 2
• Tuberculous pericarditis:
  • Standard antituberculous therapy for 6 months 3
  • Adjunctive steroids may be considered in HIV-negative cases 2
• Uremic pericarditis:
  • Intensify dialysis in patients with inadequate dialysis 2
  • Consider pericardial drainage for non-responsive cases 2
  • NSAIDs and corticosteroids may be considered when intensive dialysis is ineffective 2

Activity Restrictions

• Rest and avoidance of physical activity until resolution of symptoms and normalization of inflammatory markers, ECG, and echocardiogram 3
• Athletes should avoid competitive sports for at least 3 months, and in cases of myopericarditis, for at least 6 months 1, 3

Complications and Follow-up

• Monitor for complications such as cardiac tamponade (more common with malignancy, TB, and purulent pericarditis) 3
• Risk of constrictive pericarditis varies by etiology: low risk (<1%) for viral/idiopathic, intermediate risk (2-5%) for autoimmune/neoplastic, and high risk (20-30%) for bacterial causes 3
• Recurrence occurs in 15-30% of patients after initial episode, with increased risk to 50% after first recurrence if not treated with colchicine 3, 4

Caution and Contraindications

• Colchicine is contraindicated in patients with severe renal impairment 2
• NSAIDs should be used cautiously in patients with renal impairment, heart failure, or gastrointestinal risk factors 1
• Evaluate response to anti-inflammatory therapy after 1 week to assess treatment efficacy 2