First-Line Treatment for Acute Pericarditis
The first-line regimen for acute pericarditis is aspirin (750-1000 mg every 8 hours) or an NSAID such as ibuprofen (600 mg every 8 hours) combined with colchicine (0.5 mg twice daily if ≥70 kg, or 0.5 mg once daily if <70 kg), both with gastroprotection, continued until symptom resolution and CRP normalization. 1, 2
Core Treatment Components
Anti-Inflammatory Therapy
- Aspirin or NSAIDs are Class I, Level A recommendations as first-line therapy 1
- Aspirin dosing: 750-1000 mg every 8 hours for 1-2 weeks 3, 2
- Ibuprofen dosing: 600 mg every 8 hours for 1-2 weeks 3, 2
- Always provide gastroprotection with these agents 1
- If antiplatelet therapy is required or ischemic heart disease is a concern, aspirin should be preferred over NSAIDs 1
Colchicine as Mandatory Adjunct
- Colchicine is a Class I, Level A recommendation and must be added to aspirin/NSAIDs as part of first-line therapy, not as an optional add-on 1
- Weight-adjusted dosing is critical: 0.5 mg twice daily if ≥70 kg, or 0.5 mg once daily if <70 kg 3, 2
- Continue for 3 months minimum 2
- Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction of 20.8%) 4
- Without colchicine, recurrence rates after initial episode range from 15-30%, increasing to 50% after first recurrence 1
Treatment Duration and Monitoring
Guiding Therapy with CRP
- Serum CRP should be used to guide treatment length and assess response (Class IIa recommendation) 1
- Maintain initial doses until complete symptom resolution AND CRP normalization 1, 2
- Only begin tapering after both symptoms resolve and CRP normalizes 2
Tapering Strategy
- Taper aspirin gradually by 250-500 mg every 1-2 weeks 2
- Stop one class of drugs at a time during tapering 1
- If symptoms recur during tapering, do NOT increase corticosteroid doses; instead, maximize aspirin/NSAID dosing to every 8 hours (intravenously if necessary), add colchicine if not already prescribed, and add analgesics for pain control 1
Activity Restriction
Non-Athletes
- Exercise restriction until resolution of symptoms AND normalization of CRP, ECG, and echocardiogram (Class IIa recommendation) 1
Athletes
- Minimum 3 months of exercise restriction until symptom resolution and normalization of CRP, ECG, and echocardiogram 1, 2
When NOT to Use Corticosteroids
Corticosteroids are Class III (not recommended) as first-line therapy for acute pericarditis 1
- Corticosteroids increase risk of chronicity, recurrence, and side effects 2, 5
- They should only be considered (Class IIa) when: 1
- If corticosteroids are necessary, use LOW doses (prednisone 0.2-0.5 mg/kg/day), NOT high doses (1.0 mg/kg/day) 1
Critical Pitfalls to Avoid
Common Causes of Treatment Failure
- Inadequate treatment of the first episode is the most common cause of recurrence 1, 2
- Premature discontinuation before complete symptom resolution and CRP normalization 3, 2
- Using corticosteroids as first-line therapy, which promotes recurrence 1, 2
- Failing to add colchicine to NSAIDs, which significantly reduces recurrence 3, 2
- Inadequate colchicine duration (less than 3 months increases recurrence risk) 2
Risk Stratification for Complications
- Most patients with idiopathic/viral pericarditis have excellent prognosis 1
- Constrictive pericarditis risk: <1% for idiopathic/viral, 2-5% for autoimmune (including lupus), 20-30% for bacterial causes 1, 3
- Cardiac tamponade rarely occurs in idiopathic pericarditis (<3%) but is more common with malignancy, tuberculosis, or purulent pericarditis 1, 4
Diagnostic Requirements Before Treatment
Diagnosis requires at least 2 of the following 4 criteria: 1
- Pericardial chest pain (sharp, pleuritic, worse when supine)
- Pericardial friction rub
- ECG changes (widespread ST elevation, PR depression)
- New or worsening pericardial effusion
Transthoracic echocardiography should be performed in all patients to characterize effusion size and evaluate for complications 6