What is the management of acute pericarditis?

Management of Acute Pericarditis

First-line treatment for acute pericarditis consists of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) combined with colchicine (0.5 mg twice daily if ≥70 kg, 0.5 mg once daily if <70 kg) for 3 months, along with exercise restriction until symptoms resolve and inflammatory markers normalize. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by identifying at least 2 of the following 4 criteria: 1

• Characteristic pericardial chest pain (sharp, pleuritic, relieved by sitting forward)
• Pericardial friction rub on examination
• New or worsening pericardial effusion on echocardiography
• Typical ECG changes (widespread ST elevation, PR depression)

All patients require baseline ECG, transthoracic echocardiography, chest X-ray, and measurement of inflammatory markers (CRP, ESR) and cardiac biomarkers (troponin, CK). 1

First-Line Pharmacologic Therapy

NSAIDs with Gastroprotection

• Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours for 1-2 weeks 1, 2
• Choose aspirin if ischemic heart disease is a concern or antiplatelet therapy is required (dose range 1-2.4 g/day) 1
• Continue at full doses until complete symptom resolution 1
• Always provide gastroprotection (proton pump inhibitor) 2

Colchicine as Mandatory Adjunct

• Weight-adjusted dosing: 0.5 mg twice daily if ≥70 kg, 0.5 mg once daily if <70 kg 1, 2
• Duration: 3 months minimum 1, 2
• This combination reduces recurrence rates from 15-30% down to single digits 2
• Colchicine is contraindicated in severe renal impairment (CrCl <30 mL/min) 2, 3

Treatment Duration and Tapering

• Continue therapy until complete symptom resolution AND CRP normalization 1, 2
• Monitor CRP weekly to guide treatment duration 1
• Taper NSAIDs gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) only after symptoms resolve and CRP normalizes 2
• Stop one drug class at a time during tapering 1

Exercise Restriction

• Non-athletes: Restrict exercise until symptom resolution and CRP normalization 1
• Athletes: Minimum 3-month restriction until symptoms resolve and CRP, ECG, and echocardiogram normalize 1, 2

Second-Line Therapy: Low-Dose Corticosteroids

Corticosteroids are NOT recommended as first-line therapy due to increased risk of chronicity and recurrence. 1, 2

Consider low-dose corticosteroids ONLY when: 1, 2

• Contraindications to NSAIDs/colchicine exist
• Failure of first-line therapy after 7 days
• Infectious causes have been definitively excluded
• Patient is on anticoagulation (bleeding risk with NSAIDs) 3
• Pregnancy beyond 20 weeks gestation 4
• Systemic autoimmune disease requiring corticosteroids 5

Dosing: Prednisone 0.2-0.5 mg/kg/day (typically 25-50 mg/day) 2, 3

Corticosteroid Tapering Schedule

When using corticosteroids, taper slowly based on initial dose: 3

• 50 mg: Decrease by 10 mg every 1-2 weeks

• 50-25 mg: Decrease by 5-10 mg every 1-2 weeks
• 25-15 mg: Decrease by 2.5 mg every 2-4 weeks
• <15 mg: Decrease by 1.25-2.5 mg every 2-6 weeks

Always add colchicine when using corticosteroids to reduce recurrence risk. 2, 3

Risk Stratification and Admission Criteria

High-risk features requiring hospital admission: 1, 2

• Fever >38°C (>100.4°F)
• Subacute onset (symptoms over several days)
• Large pericardial effusion (diastolic echo-free space >20 mm)
• Cardiac tamponade
• Failure to respond to NSAIDs within 7 days
• Immunosuppression
• Trauma
• Oral anticoagulation therapy
• Myopericarditis (elevated troponin)

Low-risk patients can be managed as outpatients with follow-up at 1 week to assess treatment response. 1, 2

Management of Recurrent Pericarditis

If symptoms recur after initial treatment (after symptom-free interval of 4-6 weeks): 1

First recurrence:

• Restart aspirin/NSAIDs at full doses every 8 hours 1
• Add or continue colchicine for at least 6 months (consider longer duration based on response) 1
• Do NOT increase corticosteroid doses if patient is already on them 1

Corticosteroid-dependent recurrent pericarditis:

• Third-line options: IV immunoglobulin, anakinra (IL-1 antagonist), or azathioprine 1, 6
• These require consultation with immunology/rheumatology specialists 1

Last resort: Pericardiectomy - only after thorough trial of medical therapy at a specialized center 1

Special Populations and Situations

Renal Impairment

• Colchicine contraindicated if CrCl <30 mL/min 2
• For CrCl 30-50 mL/min: Use standard dose with close monitoring 2
• For dialysis patients: Maximum colchicine 0.3 mg twice weekly 2
• Consider corticosteroids as alternative anti-inflammatory 2

Patients on Anticoagulation

• Use low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) instead of NSAIDs due to bleeding risk 3
• Add colchicine as adjunctive therapy 3
• May need to temporarily interrupt anticoagulation for procedures (24 hours for low-risk, 3 days for high-risk procedures) 3

Autoimmune Etiology (e.g., Lupus)

• Same first-line therapy (NSAIDs + colchicine) 5
• Higher risk of constrictive pericarditis (2-5% vs <1% for idiopathic) 2, 5
• May require treatment of underlying systemic disease activity 5

Uremic Pericarditis

• Intensify dialysis as primary intervention 2
• Consider pericardial drainage if non-responsive 2
• Colchicine contraindicated in severe renal impairment 2

Tuberculous Pericarditis

• Adjunctive steroids may be considered in HIV-negative patients 2
• Avoid steroids in HIV-associated TB pericarditis 2

Purulent Pericarditis

• Immediate empiric IV antibiotics 2
• Urgent pericardial drainage required 2
• 85% survival with aggressive management 2

Critical Pitfalls to Avoid

• Inadequate treatment of the first episode is the most common cause of recurrence - ensure full-dose therapy until CRP normalizes 2, 5
• Premature tapering before symptom resolution and CRP normalization leads to recurrence 2
• Using corticosteroids as first-line therapy increases chronicity and recurrence rates 1, 2
• Omitting colchicine - this significantly increases recurrence risk from 15-30% to 50% after first recurrence 2
• Inadequate treatment duration - colchicine must be continued for at least 3 months 1, 2
• Increasing corticosteroid doses during symptom recurrence - instead, maximize NSAIDs and add colchicine 1
• Failing to exclude infectious causes before starting corticosteroids - this can worsen bacterial or tuberculous pericarditis 1

Monitoring Strategy

• Assess response to therapy at 1 week 1, 2
• Monitor CRP to guide treatment duration - continue therapy until normalization 1, 2
• Repeat echocardiography if clinical deterioration or new symptoms develop 1
• For moderate chronic effusions: Echocardiography every 6 months 2