From the Guidelines
The diagnosis and management of pericarditis should prioritize a thorough clinical evaluation, with hospital admission recommended for high-risk patients, and first-line therapy consisting of aspirin or NSAIDs, with colchicine added to reduce recurrence rates, as recommended by the 2015 ESC guidelines 1. The initial workup for pericarditis includes:
- ECG to identify characteristic changes such as widespread ST elevation or PR depression
- Echocardiography to assess for pericardial effusion
- Chest X-ray to evaluate for cardiomegaly or other abnormalities
- Blood tests, including complete blood count, cardiac biomarkers, and inflammatory markers like CRP and ESR For patients with acute pericarditis, aspirin or NSAIDs are the mainstays of therapy, with colchicine recommended at low, weight-adjusted doses to improve response to medical therapy and prevent recurrences, as supported by the 2015 ESC guidelines 1. Key considerations in the management of pericarditis include:
- Restricting physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP, with athletes recommended to return to competitive sports only after symptoms have resolved and diagnostic tests have been normalized 1
- Gastric protection with a proton pump inhibitor to accompany NSAID therapy
- Reserving corticosteroids for specific indications like autoimmune causes, NSAID contraindications, or refractory cases, and tapering slowly 1 Follow-up should include monitoring for complications like recurrence, constrictive pericarditis, or cardiac tamponade, with repeat ECG, echocardiography, and inflammatory markers, as recommended by the 2015 ESC guidelines 1.
From the Research
Diagnosis of Pericarditis
- The diagnosis of pericarditis is based on clinical criteria, including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion 2
- Certain features at presentation, such as temperature >38°C, 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 of Pericarditis
- The most common treatment for idiopathic and viral pericarditis is NSAID therapy, with adjunctive colchicine used to ameliorate the initial episode and reduce recurrence rates 3, 2
- Colchicine is effective in reducing episodes of pericarditis in people with recurrent pericarditis, with a number needed to treat (NNT) of 4 at 18 months follow-up 4
- Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine 3, 2, 5
- Recurrences may occur in 30% of patients without preventive therapy, but treatment with colchicine can reduce recurrence rates by approximately 50% 6, 2
Treatment Options
- Aspirin and non-steroidal anti-inflammatory drugs (NSAID) are the mainstay of therapy, with the possible adjunct of colchicine, especially for recurrences 3
- Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis 4
- Anti-interleukin-1 (IL-1) agents, such as anakinra and rilonacept, are a valuable option in case of recurrent pericarditis refractory to conventional drugs 6