What is the appropriate treatment for a patient with pericarditis?

Treatment of Pericarditis

For acute pericarditis, initiate combination therapy with 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 all patients, with treatment duration of 1-2 weeks for NSAIDs and 3 months for colchicine. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using at least 2 of 4 criteria: 1, 3, 4

• Sharp, pleuritic chest pain worsening when supine and improving when sitting forward (present in ~90% of cases) 5, 4
• Pericardial friction rub (present in <30% of cases) 4
• New widespread ST-elevation or PR depression on ECG (present in 25-50% of cases) 4
• New or worsening pericardial effusion on echocardiography (present in ~60% of cases) 4

Mandatory initial workup includes ECG, transthoracic echocardiography, chest X-ray, and inflammatory markers (CRP, ESR, white blood cell count). 1, 3

Risk Stratification and Triage

High-risk features requiring hospital admission include: 1, 3

• Fever >38°C (>100.4°F) 1
• Subacute course (symptoms developing over several days without clear acute onset) 1
• Large pericardial effusion (diastolic echo-free space >20 mm) 1
• Cardiac tamponade 1
• Failure to respond to NSAIDs within 7 days 1
• Myopericarditis, immunosuppression, trauma, or oral anticoagulant therapy 1

Low-risk patients without these features can be managed as outpatients with close follow-up after 1 week to assess treatment response. 1

First-Line Pharmacologic Treatment

NSAIDs with Gastroprotection

Choose one NSAID based on patient history, contraindications, and concomitant diseases: 1, 2

• Aspirin 750-1000 mg every 8 hours (preferred if patient already requires antiplatelet therapy) 1, 2
• Ibuprofen 600 mg every 8 hours 1, 2

Treatment duration: 1-2 weeks initially, guided by symptom resolution and CRP normalization. 1, 2 Taper gradually (e.g., decrease aspirin by 250-500 mg every 1-2 weeks) only after symptoms resolve and CRP normalizes. 2

Colchicine (Mandatory Addition)

Colchicine significantly reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction 20.8%) and should be added to all NSAID regimens. 4, 6

Weight-adjusted dosing: 1, 2, 3

• 0.5 mg once daily if <70 kg 1, 2
• 0.5 mg twice daily if ≥70 kg 1, 2

Treatment duration: 3 months for first episode of acute pericarditis. 1, 2, 3 For first recurrence, extend colchicine to at least 6 months. 3, 4

Contraindications and dose adjustments: 2

• Contraindicated in severe renal impairment (CrCl <30 mL/min): use 0.3 mg once daily 2
• Moderate renal impairment (CrCl 30-50 mL/min): standard dose with close monitoring 2
• Dialysis patients: maximum 0.3 mg twice weekly 2

Second-Line Treatment

Corticosteroids should be considered ONLY as second-line therapy due to risk of promoting chronicity, recurrence, and drug dependence. 1, 2

Indications for corticosteroids: 1, 2, 3

• Contraindications to NSAIDs and colchicine 1, 2
• Failure of first-line therapy after adequate trial 1, 2
• Infectious causes (especially tuberculosis) have been excluded 1, 2

Dosing: Low to moderate doses (prednisone 0.2-0.5 mg/kg/day) rather than high doses. 2 Taper gradually only after symptoms resolve and CRP normalizes. 1

Activity Restriction

Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP, ECG, and echocardiogram normalize. 1, 5

For competitive athletes: Minimum 3-month restriction from competitive sports after initial onset, regardless of symptom resolution. 1, 5 For non-athletes, restriction until remission is sufficient. 1

Monitoring Treatment Response

Evaluate response after 1 week using clinical symptoms and CRP levels. 1 Continue monitoring CRP to guide treatment duration and assess for disease activity. 1, 2

If no response to NSAIDs and colchicine after 7 days, this constitutes a high-risk feature requiring hospital admission and consideration of second-line therapy. 1

Etiology-Specific Considerations

Tuberculous Pericarditis (Endemic Areas)

In endemic areas with exudative pericardial effusion, initiate empiric anti-tuberculosis therapy after excluding other causes: 3, 5

• Isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, ethambutol 15-25 mg/kg/day 7
• Consider adjunctive prednisone 1-2 mg/kg/day for 5-7 days, tapered over 6-8 weeks (for HIV-negative patients only) 2, 7
• Treatment duration: 6 months to prevent constrictive pericarditis (reduces risk from >80% to <10%) 1, 3

Purulent Pericarditis

Immediate empiric intravenous antimicrobial therapy (vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, ciprofloxacin 400 mg/day) plus urgent drainage (surgical preferred over percutaneous). 3, 5, 7 This approach achieves 85% survival with good long-term outcomes. 2, 3

Uremic Pericarditis

Intensify dialysis as first-line treatment; consider pericardial aspiration/drainage if non-responsive. 2, 3, 5 Note that colchicine is contraindicated in severe renal impairment. 2

Histoplasmosis-Related Pericarditis

Nonsteroidal anti-inflammatory therapy alone is sufficient; antifungal therapy is NOT needed. 1 If corticosteroids are required for hemodynamic compromise (prednisone 0.5-1.0 mg/kg daily tapered over 1-2 weeks), add itraconazole 200 mg once or twice daily for 6-12 weeks. 1

Neoplastic Pericarditis

Systemic antineoplastic treatment is baseline therapy (prevents recurrence in up to 67% of cases). 1 Pericardiocentesis for symptom relief and diagnosis, with consideration of intrapericardial instillation of cytostatic/sclerosing agents (cisplatin for lung cancer, thiotepa for breast cancer). 1

Common Pitfalls and Caveats

Inadequate treatment of the first episode is the most common cause of recurrence. 2 Ensure full treatment duration: NSAIDs for 1-2 weeks (with gradual taper) and colchicine for full 3 months. 1, 2

Corticosteroids provide rapid symptom control but increase risk of chronicity and recurrence—reserve as second-line only. 1, 2 When used, employ low doses and taper slowly. 2

Recurrence rates are 15-30% without colchicine, increasing to 50% after first recurrence. 2, 4, 6 This underscores the critical importance of colchicine in initial treatment. 4, 6

Do not use colchicine for isolated pericardial effusion without inflammation (normal CRP)—it is ineffective and increases side effects without benefit. 2 Anti-inflammatory drugs only work when systemic inflammation is present. 2

For moderate pericardial effusion with normal CRP, target the underlying etiology rather than empiric anti-inflammatory therapy. 2 Monitor with echocardiography every 6 months, as large chronic effusions carry 30-35% risk of progression to tamponade. 2

Risk of constrictive pericarditis varies by etiology: <1% for idiopathic/viral, 2-5% for autoimmune/neoplastic, and 20-30% for bacterial causes. 2 This risk stratification should guide intensity of follow-up. 2