What is the treatment and follow-up for pericarditis?

Treatment and Follow-Up for Pericarditis

First-line treatment for acute pericarditis consists of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) PLUS colchicine (weight-adjusted: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) for 3 months, with gastroprotection mandatory. 1, 2

Initial Pharmacologic Management

First-Line Therapy (Class I Recommendation)

• NSAIDs with gastroprotection are the cornerstone of treatment 1, 2:

  • Aspirin: 750-1000 mg every 8 hours for 1-2 weeks 1, 2
  • Ibuprofen: 600 mg every 8 hours for 1-2 weeks 1, 2
  • Choice depends on patient history, contraindications, and concomitant diseases (favor aspirin if already on antiplatelet therapy) 1

• Colchicine must be added as adjunctive first-line therapy (NOT optional) 1, 2:

  • Dosing: 0.5 mg once daily if <70 kg; 0.5 mg twice daily if ≥70 kg 1, 2
  • Duration: 3 months minimum 1, 2
  • Reduces recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) 3
  • Tapering not mandatory but can consider 0.5 mg every other day in final weeks 1

Treatment Duration and Tapering

• Continue NSAIDs until symptom resolution AND CRP normalization (typically 1-2 weeks) 1
• Taper NSAIDs gradually 1, 2:
  • Aspirin: decrease by 250-500 mg every 1-2 weeks 1
  • Ibuprofen: decrease by 200-400 mg every 1-2 weeks 1
• CRP should guide treatment length and assess therapeutic response 1

Second-Line Therapy

Corticosteroids are NOT first-line due to increased risk of chronicity, recurrence, and drug dependence 1, 2, 4:

• Reserve for: contraindication/failure of NSAIDs and colchicine, autoimmune disease, or pregnancy 1, 2
• Dosing: LOW to moderate doses only (prednisone 0.2-0.5 mg/kg/day, NOT 1.0 mg/kg/day) 1
• Must exclude infectious causes before initiating 1
• Maintain initial dose until symptom resolution and CRP normalization, then taper slowly 1
• When used, combine with colchicine 1

Risk Stratification and Disposition

High-Risk Features Requiring Admission 1:

• Fever >38°C 5
• Large pericardial effusion (>20 mm) 5
• Cardiac tamponade 5
• Failure to respond to NSAIDs within 7 days 5
• Specific etiology suspected (tuberculosis, purulent, neoplastic) 1

Low-Risk Cases 1:

• Outpatient management with NSAIDs plus colchicine 1, 2
• No admission or extensive etiology search needed 1

Moderate-Risk Cases 1:

• Admission for etiology search and monitoring 1

Activity Restriction

• Non-athletes: restrict physical activity beyond ordinary sedentary life until symptom resolution AND CRP normalization 1
• Athletes: minimum 3-month restriction from competitive sports after initial onset, return only after symptoms resolve AND CRP, ECG, and echocardiogram normalize 1, 2

Follow-Up Monitoring

• Serial CRP measurements to guide treatment duration and assess response 1
• Monitor for recurrence (occurs in 15-30% without colchicine, 50% after first recurrence) 2, 3
• ECG and echocardiogram to document normalization before activity resumption 1

Recurrent Pericarditis Management

• First recurrence: continue colchicine for at least 6 months 3, 4
• Multiple recurrences: consider IL-1 blockers (anakinra, rilonacept) as third-line or second-line if glucocorticoids contraindicated 4, 6
• IL-1 blockers reduce recurrence from 78% to 10% (RR 0.14) 6

Critical Pitfalls to Avoid

• Inadequate treatment of first episode is the most common cause of recurrence 2, 5
• Premature tapering before CRP normalization leads to recurrence 5
• Using corticosteroids as first-line increases chronicity risk and recurrence rates 1, 2, 4
• Omitting colchicine from initial regimen significantly increases recurrence risk 2, 3
• Rapid tapering (within 1 month) of anti-inflammatory drugs increases recurrence 4

Prognosis by Etiology

• Constrictive pericarditis risk 2:
  • Idiopathic/viral: <1%
  • Autoimmune/neoplastic: 2-5%
  • Bacterial: 20-30%
• Tamponade risk: rare in idiopathic (<3%), higher with malignancy or purulent causes 2, 3