From the Guidelines
The workup for pericarditis should include a thorough history and physical examination, followed by an ECG, which typically shows diffuse ST-segment elevation and PR depression, as recommended by the 2015 ESC guidelines 1. The initial evaluation should also include laboratory tests such as inflammatory markers (ESR, CRP), complete blood count, cardiac biomarkers (troponin), and renal function tests.
- Chest X-ray may show an enlarged cardiac silhouette if pericardial effusion is present.
- Echocardiography is essential to assess for pericardial effusion, tamponade, or myocardial involvement, as it provides valuable information on the pericardial space and cardiac function 1. For most cases of acute pericarditis, first-line treatment consists of NSAIDs (ibuprofen 600-800mg three times daily or indomethacin 25-50mg three times daily) for 1-2 weeks, with gradual tapering over 2-4 weeks.
- Colchicine (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) should be added for 3 months to reduce recurrence risk, as demonstrated in recent clinical trials 1. Corticosteroids (prednisone 0.25-0.5mg/kg/day) should be reserved for refractory cases or specific etiologies.
- Rest and activity restriction, particularly avoiding competitive sports until resolution of symptoms and normalization of inflammatory markers, is recommended. Additional testing such as CT, MRI, or pericardiocentesis may be necessary in complicated cases or when specific etiologies are suspected, as outlined in the 2015 ESC guidelines 1. This approach targets inflammation while investigating potential underlying causes, which may include viral infections, autoimmune disorders, post-cardiac injury, or other systemic diseases.
- The use of multimodality imaging, including echocardiography, CT, and MRI, has become an essential approach for a modern and comprehensive diagnostic evaluation of pericardial diseases 1.
From the Research
Pericarditis Workup
- The diagnosis of pericarditis requires at least two of the following criteria: new or worsening pericardial effusion, characteristic pleuritic chest pain, pericardial friction rub, or electrocardiographic changes, including new, widespread ST elevations or PR depressions 2
- Transthoracic echocardiography should be performed in all patients with acute pericarditis to characterize the size of effusions and evaluate for complications 2
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment option for acute pericarditis 2, 3
- Colchicine should be used in combination with first- or second-line treatments to reduce the risk of recurrence 4, 2, 3
Treatment Options
- Aspirin or NSAIDs are the mainstay of therapy for acute and recurrent pericarditis 5, 4, 3
- Corticosteroids are a second choice for difficult cases requiring multi-drug therapies and specific medical conditions 5, 4, 2
- Immunosuppressive agents, including azathioprine, methotrexate, and mycophenolate mofetyl, seem efficacious and well tolerated in patients with idiopathic recurrent pericarditis unresponsive to corticosteroids 5
- Anti-interleukin-1 (IL-1) agents, such as anakinra and rilonacept, are a valuable option in case of recurrent pericarditis refractory to conventional drugs 3
Risk of Recurrence
- Recurrence is the most frequent complication following acute pericarditis and may occur in 30% of patients, rising to 50% in case of multiple recurrences, lack of colchicine treatment, or use of glucocorticoids 3
- Colchicine is effective in the reduction of recurrent pericarditis, compared with standard treatment 3
- Anti-IL1 agents are effective in the reduction of recurrences, compared with placebo 3