Hospital Admission for Acute Pericarditis
Not all patients with acute pericarditis require hospital admission—only those with at least one major or minor risk factor need to be admitted for further workup and treatment. 1
Risk Stratification Framework
The 2015 ESC Guidelines provide a clear triage system that determines whether admission is necessary 1:
Major Risk Factors (Any One Mandates Admission)
- Fever >38°C (>100.4°F) 1
- Subacute onset (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
Minor Risk Factors (Increase Vigilance, Consider Admission)
- Myopericarditis (concurrent myocardial involvement) 1, 2
- Immunosuppression 1, 2
- Recent trauma 1, 2
- Oral anticoagulant therapy 1, 2
Low-Risk Patients: Outpatient Management
Patients without any major or minor risk factors can be safely managed as outpatients with empiric anti-inflammatory therapy. 1, 2 This approach has been validated in large cohorts showing no serious complications (including zero cases of cardiac tamponade) during follow-up when proper selection criteria are applied 3.
Outpatient Management Protocol
Low-risk patients should receive 1, 4:
- High-dose NSAIDs: Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours 1, 4
- Colchicine: 0.5 mg once daily (<70 kg) or 0.5 mg twice daily (≥70 kg) for 3 months 1, 4
- Gastroprotection with proton pump inhibitor 4
- Follow-up at 1 week to assess response to therapy 1
High-Risk Patients: Mandatory Admission
Any patient with at least one predictor of poor prognosis warrants hospital admission and a complete etiologic workup. 1, 2 These patients have significantly higher rates of complications, including tamponade, recurrences, and constriction 1.
Inpatient Workup Should Include
- Comprehensive laboratory evaluation for specific etiologies (tuberculosis in endemic areas, autoimmune diseases, malignancy) 1, 5
- Serial echocardiography to monitor effusion size and detect early tamponade 1
- Consideration of advanced imaging (CT or cardiac MRI) if diagnosis uncertain 1
- Pericardiocentesis if tamponade present or if purulent, tuberculous, or neoplastic pericarditis suspected 5
Common Pitfalls to Avoid
Never discharge a patient who fails to respond to NSAIDs within the first week—this is itself a major risk factor requiring admission and further investigation 1. Studies show that aspirin-resistant cases have dramatically higher recurrence rates (60.6% vs 10.4%) and constriction rates (9.1% vs 0.5%) compared to responders 3.
Do not assume all pericarditis requires hospitalization—84.7% of patients in validation studies were safely managed as outpatients using proper risk stratification 3. Routine hospitalization of low-risk cases is unnecessary and increases healthcare costs without improving outcomes 5, 3.
Always assess CRP levels at baseline and follow-up—failure of CRP to normalize despite treatment suggests either non-compliance, inadequate dosing, or an underlying specific etiology requiring admission 1, 4.