How is pericarditis managed in clinical settings?

Management of Pericarditis in Clinical Settings

The management of pericarditis should follow a stepwise approach with first-line therapy consisting of aspirin or NSAIDs plus colchicine, and exercise restriction until symptoms resolve and CRP normalizes. 1

Diagnosis

Diagnosis of acute pericarditis requires at least 2 of the following 4 criteria:

• Pericardial chest pain (typically sharp, pleuritic, improves with sitting forward) 1, 2
• Pericardial friction rub (best heard with patient sitting upright, leaning forward) 1, 2
• ECG changes (widespread concave ST elevation and PR depression) 1, 2
• Pericardial effusion (present in approximately 60% of cases) 1, 2

Additional diagnostic workup includes:

• Assessment of inflammatory markers (CRP, ESR, WBC count) 1
• Cardiac biomarkers (troponin, CK) to identify myocardial involvement 1
• Transthoracic echocardiography in all suspected cases 1
• Chest X-ray (may be normal unless large effusion present) 1

Treatment Algorithm

First-Line Therapy

• Aspirin (1500-3000 mg/day) or NSAIDs (ibuprofen 1200-2400 mg/day or indomethacin 75-150 mg/day) until symptom resolution 1, 3
• Colchicine (0.5 mg twice daily or 0.5 mg once daily for patients <70 kg) for 3-6 months as adjunct to aspirin/NSAIDs 1, 4
• Exercise restriction until symptoms resolve and CRP normalizes 1

Second-Line Therapy

• Low-dose corticosteroids (0.25-0.5 mg/kg/day of prednisone) only when:
  • Contraindications to aspirin/NSAIDs/colchicine exist 1
  • Incomplete response to first-line therapy 1
  • Infectious causes have been excluded 1
• Taper corticosteroids gradually according to symptoms and CRP normalization 1

Third-Line Therapy (for Refractory Recurrent Cases)

• Immunoglobulins, anakinra (IL-1 receptor antagonist), or azathioprine for corticosteroid-dependent cases not responsive to colchicine 1, 4

Fourth-Line Therapy

• Pericardiectomy as last resort after thorough trial of unsuccessful medical therapy 1

Special Considerations

Myopericarditis Management

• Hospitalization recommended for diagnosis and monitoring 1
• Similar management to pericarditis but some authors recommend reduced NSAID dosages 1
• Extended exercise restriction (at least 6 months from onset) 1
• Coronary angiography recommended to rule out acute coronary syndromes 1
• Cardiac MRI recommended to confirm myocardial involvement 1

Post-MI Pericarditis (Dressler's Syndrome)

• Acetaminophen for symptomatic relief of early post-MI pericarditis 1
• For persistent symptoms or late pericarditis:
  • High-dose aspirin (500-1000 mg every 6-8 hours) until symptoms improve 1
  • Colchicine (0.5-0.6 mg once or twice daily) for 3 months 1
• Avoid NSAIDs (other than aspirin) and glucocorticoids due to potential increased risk of recurrent MI, impaired myocardial healing, and rupture 1

Treatment Duration and Tapering

• Continue full-dose anti-inflammatory therapy until complete symptom resolution 1
• After CRP normalization, gradually taper therapies one drug at a time 1
• Colchicine should be continued for at least 3-6 months 1, 4
• For corticosteroids, follow specific tapering schedule based on dose:

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

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

Common Pitfalls and Caveats

• Avoid high-dose corticosteroids as they increase risk of recurrences 1, 5
• Avoid NSAIDs in post-MI pericarditis (except aspirin) due to risk of myocardial rupture 1
• Normal echocardiogram does not exclude pericarditis as effusion is present in only 60% of cases 2
• Multiple auscultatory examinations may be necessary as friction rubs can be intermittent 2
• Elevated troponin (found in up to 50% of patients) indicates myopericardial involvement and necessitates additional precautions 1, 2
• Outpatient management is appropriate for low-risk patients, but hospitalization is recommended for those with risk factors or myocardial involvement 1, 6