What are the clinical presentations, affected patient populations, and management strategies for pericarditis (inflammation of the pericardium)?

From the Guidelines

Pericarditis is a condition that typically presents with sharp, pleuritic chest pain and is usually treated with NSAIDs and colchicine, with corticosteroids reserved for refractory cases or specific etiologies, as recommended by the 2015 ESC guidelines 1.

Presentation and Diagnosis

Pericarditis most commonly affects young to middle-aged adults, particularly males, and is usually viral in etiology. Other causes include bacterial infections, autoimmune disorders, myocardial infarction, trauma, and medications. Patients often have a pericardial friction rub on auscultation, diffuse ST-segment elevation on ECG, and may show pericardial effusion on echocardiography. Initial workup includes:

• ECG
• Cardiac biomarkers (troponin)
• Inflammatory markers (ESR, CRP)
• Chest X-ray
• Echocardiography

Management and Treatment

First-line treatment consists of:

• NSAIDs such as ibuprofen (600-800mg three times daily) or indomethacin (25-50mg three times daily) for 1-2 weeks
• Colchicine (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) for 3 months to prevent recurrence Corticosteroids like prednisone (0.25-0.5mg/kg/day) are reserved for refractory cases or specific etiologies. Patients should restrict strenuous physical activity until symptoms resolve and CRP normalizes. Hospitalization is warranted for high-risk features including fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, or failure to respond to NSAIDs.

Recurrent Pericarditis

Approximately 15-30% of patients develop recurrent pericarditis, which may require longer-term colchicine therapy or immunosuppressive agents like azathioprine or anakinra in resistant cases. The use of colchicine has been demonstrated to improve the response to therapy, increase remission rates, and reduce recurrences 1.

Key Recommendations

• Hospital admission is recommended for high-risk patients with acute pericarditis 1
• Colchicine use is recommended as first-line therapy for acute pericarditis as an adjunct to aspirin/NSAIDs therapy 1
• Corticosteroids are not recommended as first-line therapy for acute pericarditis 1
• CRP should be considered to guide the treatment duration and assess the response to therapy 1

From the Research

Presentation of Pericarditis

• Pericarditis is the most common form of pericardial disease and a relatively common cause of chest pain 2
• The etiology of pericarditis may be infectious (eg, viral and bacterial) or noninfectious (eg, systemic inflammatory diseases, cancer, and post-cardiac injury syndromes) 2
• Idiopathic, presumed viral causes are responsible for 80% to 90% of cases in developed countries 2
• Tuberculosis is a major cause of pericarditis in developing countries but accounts for less than 5% of cases in developed countries 2

Patient Characteristics

• Pericarditis can occur in adults of any age, with a mean age of 45.4 ± 12.7 years in one study 3
• Males are significantly higher in number and younger than females 3
• Certain features at presentation (temperature >38°C [>100.4°F], subacute course, large effusion or tamponade, and failure of nonsteroidal anti-inflammatory drug [NSAID] treatment) indicate a poorer prognosis and identify patients requiring hospital admission 2

Management and Workup

• The diagnosis is based on clinical criteria including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion 2
• The most common treatment for idiopathic and viral pericarditis in North America and Europe is NSAID therapy 2
• Adjunctive colchicine can ameliorate the initial episode and is associated with approximately 50% lower recurrence rates 2, 4
• Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine 5, 2
• Immunotherapy, such as anakinra, intravenous immunoglobulin (IVIG), and azathioprine, may be considered for patients with multiple recurrences of pericarditis 6
• Steroids at low dose, with very gradual tapering, may be a successful and safe treatment for acute and recurrent idiopathic pericarditis 3