Causes and Treatment of Pericarditis
Etiology
Viral infections are the most common cause of pericarditis in developed countries, while tuberculosis dominates globally, especially in endemic regions. 1
Common Causes by Geographic Region
Developed Countries (North America/Western Europe):
- Idiopathic or viral pericarditis (most common) - caused by enteroviruses, herpesviruses, parvovirus B19, influenza viruses, and HIV 1, 2
- Post-cardiac injury syndromes following cardiac surgery, percutaneous coronary interventions, pacemaker insertion, and catheter ablation 1
Developing Countries/Endemic Areas:
- Tuberculous pericarditis accounts for >90% of cases in HIV-infected individuals and 50-70% in non-HIV-infected individuals 1
Other Important Causes
- Autoimmune disorders including systemic lupus erythematosus, rheumatoid arthritis, and systemic sclerosis 1
- Neoplastic pericarditis from primary tumors or metastatic disease (lung cancer, breast cancer, lymphoma, leukemia) 1
- Bacterial pericarditis from Staphylococcus, Streptococcus, Haemophilus, or Mycobacterium tuberculosis, occurring via direct infection during trauma/surgery, spread from intrathoracic foci, or hematogenous dissemination 3
First-Line Treatment
Aspirin or ibuprofen combined with colchicine is the recommended first-line therapy for acute pericarditis. 4, 5
NSAIDs/Aspirin Dosing
- Aspirin: 750-1000 mg every 8 hours for 1-2 weeks 4, 5
- Ibuprofen: 600 mg every 8 hours for 1-2 weeks 4, 5
- Gastroprotection is mandatory with all NSAID therapy 4, 5
- Treatment duration should be guided by symptom resolution and C-reactive protein (CRP) normalization 4, 5
- Tapering is essential: Decrease aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks 4, 5
Colchicine (Must Be Added to NSAIDs)
- Weight-adjusted dosing: 0.5 mg once daily if <70 kg OR 0.5 mg twice daily if ≥70 kg 4, 5
- Duration: 3 months minimum 4, 5
- Colchicine reduces recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) 2
- Tapering is not mandatory but may use 0.5 mg every other day (<70 kg) or 0.5 mg once daily (≥70 kg) in final weeks 4
Second-Line Treatment
Corticosteroids should only be used when NSAIDs/colchicine fail or are contraindicated, and NEVER as first-line therapy. 4, 5, 1
Corticosteroid Use
- Low to moderate doses only: Prednisone 0.2-0.5 mg/kg/day 4, 5, 1
- Must exclude infectious causes before initiating 1
- Always combine with colchicine when using corticosteroids 4
- Major caveat: Corticosteroids increase risk of chronicity, recurrence, and drug dependence 4, 5, 1
Treatment Algorithm by Risk Stratification
High-Risk Features Requiring Admission
- Fever >38°C (100.4°F) 4
- Subacute course (symptoms over several days without clear acute onset) 4
- Large pericardial effusion (diastolic echo-free space >20 mm) 4
- Cardiac tamponade 4
- Failure to respond to NSAIDs within 7 days 4
- Myopericarditis, immunosuppression, trauma, or oral anticoagulant therapy 4
Low-Risk Cases
- Outpatient management with NSAIDs + colchicine 4, 5
- Monitor CRP to guide treatment duration and assess response 5
Moderate-Risk Cases
- Admission and etiology search 4
Activity Restriction
Physical activity must be restricted beyond ordinary sedentary life until complete resolution. 4, 5
- Restriction continues until symptoms resolve AND CRP, ECG, and echocardiogram normalize 4, 5
- For athletes: Minimum 3-month restriction from competitive sports after initial onset 4, 5
- For non-athletes: Restriction until remission is achieved 4
Specific Etiologies Requiring Targeted Therapy
Tuberculous Pericarditis
- Initial treatment: Isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day 3
- Prednisone 1-2 mg/kg/day for 5-7 days, then progressively reduced over 6-8 weeks 3
- Drug sensitivity testing is essential 3
- Mortality approaches 85% if untreated 3
Purulent/Bacterial Pericarditis
- Urgent pericardial drainage is mandatory 3
- Intravenous antibiotics: Vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, and ciprofloxacin 400 mg/day 3
- Open surgical drainage is preferable to catheter drainage 3
- Mortality rate is 40% even with treatment 3
Histoplasma Pericarditis
- Antifungal therapy is NOT recommended 4
- NSAIDs for 2-12 weeks based on clinical resolution 4
- Corticosteroids may be tried for 1-2 weeks if hemodynamic compromise, followed by NSAIDs 4
- If corticosteroids used, consider concurrent itraconazole 200 mg once or twice daily for 12 weeks 4
- Percutaneous or surgical drainage for pericardial tamponade 4
Refractory Recurrent Pericarditis
For patients with multiple recurrences refractory to conventional therapy, IL-1 antagonists are highly effective. 5, 2, 6
- Anti-IL-1 agents (anakinra, rilonacept) reduce recurrences from 78% to 10% (RR=0.14) 6
- Consider after failure of NSAIDs, colchicine, and corticosteroids 7, 2
- Alternative options include azathioprine or intravenous immunoglobulins 4
- Pericardiectomy is a last resort for truly refractory cases 4
Critical Pitfalls to Avoid
- Inadequate treatment of the first episode is the most common cause of recurrence 5
- Never use corticosteroids as first-line therapy - they provide rapid symptom relief but dramatically increase recurrence risk 4, 5, 1
- Never taper medications until symptoms are absent AND CRP is normalized 5
- Recurrence rates: 15-30% after first episode without colchicine, rising to 50% after first recurrence 5, 2, 6
- For first recurrence, extend colchicine to at least 6 months 2
Prognosis by Etiology
Constrictive Pericarditis Risk
- Low risk (<1%): Idiopathic/viral pericarditis 5, 1
- Intermediate risk (2-5%): Autoimmune/neoplastic causes 5, 1
- High risk (20-30%): Bacterial pericarditis 5, 1