From the Guidelines
Pericarditis should be treated with a combination of non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, with the goal of relieving symptoms, addressing the underlying cause, and preventing recurrence, as recommended by the 2015 ESC guidelines 1, 2, 3. The diagnosis of pericarditis is based on a combination of clinical symptoms, physical examination, and diagnostic tests, including:
- Characteristic chest pain that worsens when lying flat and improves when leaning forward
- Pericardial friction rub on auscultation
- Typical ECG changes (widespread ST-segment elevation or PR depression)
- Pericardial effusion on imaging Additional tests include echocardiography, chest X-ray, and blood tests for inflammatory markers like C-reactive protein and troponin.
Treatment of acute pericarditis focuses on relieving symptoms and addressing the underlying cause.
- First-line therapy includes NSAIDs such as ibuprofen (600-800mg three times daily) or aspirin (750-1000mg every 8 hours) for 1-2 weeks, followed by gradual tapering over 2-4 weeks, as outlined in the 2015 ESC guidelines 1.
- Colchicine (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) should be added to NSAIDs for 3 months to improve response and prevent recurrence, as recommended by the guidelines 2, 3.
- Gastrointestinal protection with proton pump inhibitors is recommended during NSAID treatment.
- For refractory or recurrent cases, corticosteroids like prednisone (0.25-0.5mg/kg/day) may be used, but should be tapered slowly to prevent recurrence, as suggested by the guidelines 2, 3.
- Rest and activity restriction, particularly avoiding competitive sports until resolution of symptoms and normalization of inflammatory markers, is important during the acute phase.
- Treatment should be continued until complete symptom resolution and normalization of inflammatory markers, typically 1-3 weeks for acute cases.
It is essential to note that the recurrence rate after an initial episode of pericarditis ranges from 15 to 30%, and may increase to 50% after a first recurrence in patients not treated with colchicine, particularly if treated with corticosteroids, as highlighted in the guidelines 4. Therefore, the use of colchicine as an adjunct to NSAIDs is crucial in preventing recurrence and improving outcomes in patients with pericarditis.
From the Research
Diagnosis of Pericarditis
- Pericarditis is diagnosed with the presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine, new widespread electrocardiographic ST-segment elevation and PR depression, a new or increased pericardial effusion, or a pericardial friction rub 5
- The most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations 5
- Tuberculosis is the most common cause of pericarditis in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis 5
Treatment of Pericarditis
- Empiric anti-inflammatory therapy for acute and recurrent pericarditis is warranted for viral and idiopathic cases, with aspirin and non-steroidal anti-inflammatory drugs (NSAID) as the mainstay of therapy 6
- Colchicine is often used as an adjunct to NSAIDs, especially for recurrences, and can reduce recurrence rates by approximately 50% 7, 8
- Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine 6, 5, 8
- Interleukin 1 (IL-1) blockers have demonstrated efficacy in reducing recurrences and may be preferred to corticosteroids in certain patients with multiple recurrences 5, 7
Management of Pericarditis
- Medical therapy of pericarditis should be targeted at its etiology and individualized as much as possible 9
- A correct pharmacological management of pericarditis is key to prevent recurrences, with colchicine as the mainstay of treatment in acute and recurrent pericarditis 7
- Patients with multiple recurrent pericarditis can have a disease duration of several years or more and may require long-term treatment with colchicine, corticosteroids, or IL-1 blockers 5, 7