🫀 Mirza's Cardiology Notes

Pericarditis

9 min read

TherapyDosingDurationTaperingMonitoringLOE
Aspirin500-1,000 mg 3 times dailywks (acute) to mo (recurrent)WeeklyNeededA
Ibuprofen600-800 mg 3 times dailywks (acute) to mo (recurrent)WeeklyNeededA
Indomethacin25-50 mg 3 times dailywks (acute) to mo (recurrent)WeeklyNeededB
Colchicine0.6 mg twice daily or 0.6 mg once daily (<70 kg, severe renal/hepatic impairment)3 mo (acute), 6-12 mo (recurrent)May be consideredNeededA
Prednisone0.2-0.5 mg/kg/dwks to moSeveral moNeededB
Anti–IL-1 agents
Anakinra1-2 mg/kg/d up to 100 mg/d in adults>12 moNeededNeededA
Rilonacept320 mg once followed by 160 mg weekly>12 moStopping vs tapering under investigationNeededA
Goflikicept (Not yet available in United States)80 mg every 2 wks>12 mo (under investigation)UnknownNeededB
AzathioprineStarting with 1 mg/kg per d then gradually increased to 2-3 mg/kg/dSeveral moSeveral moNeededC
IVIG400 to 500 mg/kg IV daily for 5 d5 dNot requiredNeededC
Radical pericardiectomyHigh-volume pericardial surgical centersNot applicableNot applicableNeededC
Table source: 1

Acute Pericarditis

# Acute pericarditis
- Work-up: CBC, ESR, CRP (abnormal if > 3 mg/L), CK, troponin (assess for epicardial inflammation; if significantly elevated consider myopericarditis), 12-lead ECG, CXR
	- Consider TB testing in the appropriate context
- Echo
	- If acute pericarditis and LV dysfunction, most (85%) will have recovery after 12 months
- Empiric therapy
	- Aspirin 750-1,000 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 250-500 mg every 1-2 weeks
	- Ibuprofen 600 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 200-400 mg every 1-2 weeks.
	- 3 month course of Colchicine 0.5 mg BID (if weight > 70 kg) or 0.5 mg daily (if weight < 70 kg) (based on 2013 ICAP study)
	- PPI for gastroprotection (if prescribed ASA or NSAIDs)
- Activity limitations
	- If not involved in athletic sports, recommend restrict physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP
	- If athlete, recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG and echocardiogram) have normalized
	- Duration: Expert consensus recommends activity restriction for a minimum of 3 months for athletes, whereas a shorter period (until remission) may be suitable for non-athletes.
- Dispo: close follow-up in 1 week to assess therapeutic response
  • Acute pericarditis is an inflammatory pericardial syndrome with or without pericardial effusion.
  • With appropriate treatment, 70% to 85% of these patients have a benign course.2
  • In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening.2
  • Causes
    • In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations.
    • Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis.
  • Among patients with a malignant pericardial effusion, the most common causes are lung (≈40%), breast (≈25%), and hematologic (≈20%) malignancies.2
  • Poor prognostic markers – if present, may warrant hospital admission
    • Fever
    • Subacute course, i.e. Sx over several days w/o a clear-cut onset
    • Large pericardial effusion, i.e. diastolic echo-free space >2 cm
    • Cardiac tamponade
    • Failure to respond w/in 7 days to NSAIDs

Diagnosis of Acute Pericarditis

  • Clinical diagnosis can be made with ≥2 of the following criteria:
    • chest pain (>85–90% of cases)—typically sharp and pleuritic, improved by sitting up and leaning forward; worsens when supine
    • pericardial friction rub (≤33% of cases)—a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope 🩺 over the left sternal border
    • ECG changes (up to 60% of cases)—with new widespread ST elevation or PR depression in the acute phase
      • NOTE: ECG changes imply inflammation of the epicardium, since the parietal pericardium itself is electrically inert
    • pericardial effusion (up to 60% of cases, generally mild)
  • CRP, ESR, WBC elevation is common and may be helpful to monitor disease activity and therapeutic efficacy
  • Increased markers of myocardial injury (e.g. CK, troponin) may suggest concomitant myocarditis

ECG in Pericarditis

You may not always seen diffuse ST-segment elevation, so absence should not exclude Dx of pericarditis.

Source: 3

Imaging in Pericarditis

TTECCTCMR
▪ Normal findings in some patients. Pericardial thickening▪ Noncalcified pericardial thickening (>3 mm)▪ Thickening of pericardium at T1-weighted BB images (>3 mm)
▪ Segmental wall motion abnormalities or pathological myocardial strain values (in case of myocarditis)▪ Enhancement of the thickened visceral and parietal surfaces of the pericardial sac at late postcontrast CT scan▪ Enhancement of pericardium on LGE sequence (inflammation) and T2-STIR sequence (edema) consistent with active inflammation and neovascularization (of prognostic importance)
▪ LGE+/T2-STIR+: acute/subacute phase or recurrent flares
▪ LGE+/T2-STIR-: subacute or chronic phase
▪ LGE-/T2-STIR-: resolution or end-stage/calcific phase
▪ PEff with or without Tamponade (present in 40%-50% of cases)▪ PEff presence. CT attenuation values of the PEff may help distinguish between exudative and transudative fluid (on noncontrast CT)▪ PEff presence. High signal intensity on T1-weighted BB images is suggestive of exudative PEffs
▪ Sign of CP (often transient)▪ Loss of the normal sliding between pericardial layers during the cardiac cycle is one feature consistent with pericarditis
Table source: 1

Figure source: 1

Management of Acute Pericarditis

Table source: 4

DrugUsual DosingTx DurationTapering
Aspirin750-1,000 mg q8h1-2 wks↓ dose by 250-500 mg every 1-2 wks
Ibuprofen600 mg q8h1-2 wks↓ dose by 200-400 mg every 1-2 wks
Colchicine0.5 mg daily (< 70 kg) or 0.5 mg BID (≥ 70 kg)3 monthsNot mandatory, alternatively 0.5 mg every other day (< 70 kg) or 0.5 mg once (270 kg) in the last weeks
  • Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and CRP level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%).2
  • Empiric therapy
    • Aspirin 750-1,000 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 250-500 mg every 1-2 weeks
    • Ibuprofen 600 mg q8h for 1-2 weeks. If response, plan to taper by decreasing dose by 200-400 mg every 1-2 weeks.
    • Colchicine 0.6 mg BID (if weight > 70 kg) or 0.5 mg daily (if weight < 70 kg). Often prescribed as adjunct to Aspirin/NSAID. Tapering is not mandatory.
      • Contraindicated if severe renal impairment, pregnant/lactating women
    • 📝 Steroids only used if contraindications and failure to ASA/NSAIDs. If used, low to moderate doses (i.e. prednisone 0.2-0.5 mg/kg/day or equivalent) should be recommended instead of high doses (i.e. prednisone 1.0 mg/kg/day or equivalent). initial dose should be maintained until resolution of symptoms and normalization of CRP, then tapering should be considered.
      • ⚠️ In observational studies, corticosteroids, especially at higher doses (eg, prednisone [1.0 mg/kg daily]), have been associated with an increased risk of recurrence of pericarditis. ∴, corticosteroids should only be prescribed at low to moderate doses (prednisone [0.25-0.5 mg/kg daily]) in patients who do not improve with NSAIDS and colchicine or have adverse outcomes with or contraindications to NSAIDs and colchicine. 2
  • PPI for gastroprotection (if prescribed ASA or NSAIDs)
  • Activity limitations
    • If not involved in athletic sports, recommend restrict physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP
    • If athlete 🏃, recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG and echocardiogram) have normalized
    • Duration: Expert consensus recommends activity restriction for a minimum of 3 months for athletes, whereas a shorter period (until remission) may be suitable for non-athletes.
  • Dispo: close follow-up in 1 week to assess therapeutic response

Incessant Pericarditis

  • Incessant pericarditis is defined by symptoms lasting at least 4 to 6 weeks but less than 3 months without remission.2
  • 20% of patients with incessant pericarditis develop constrictive pericarditis 2

Recurrent Pericarditis

Algorithm source: 1

  • Try to target underlying etiology (if identifiable cause present)
  • Aspirin or NSAIDs remain the mainstay of therapy + Colchicine as adjunct
  • If incomplete response to ASA/NSAID + colchicine combo, then can consider steroids as an add-on to low-/moderate-dose ASA/NSAID + colchicine, i.e. ‘triple therapy’
    • See ESC 2015 guidelines for recommendations on tapering steroid therapy

  • Drugs such as IVIG, anakinra and azathioprine may be considered in cases of proven infection-negative, corticosteroid-dependent, recurrent pericarditis not responsive to colchicine after careful assessment of the costs, risks and eventually consultation by multidisciplinary experts, including immunologists and/or rheumatologists, in the absence of a specific expertise. It is also mandatory to educate the patient and his/her caregivers about the clinical risks related to immunomodulatory/immunosuppressive drugs and the safety measures to adopt during the treatment.
  • As a last resort, pericardiectomy may be considered, but only after a thorough trial of unsuccessful medical therapy, and with referral of the patient to a centre with specific expertise in this surgery.

Chronic Pericarditis

Footnotes

  1. Wang TKM, Klein AL, Cremer PC, Imazio M, Kohnstamm S, Luis SA, Mardigyan V, Mukherjee M, Ordovas K, Vakamudi S, Wohlford GF. 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025 Jul 31:S0735-1097(25)06503-9. doi: 10.1016/j.jacc.2025.05.023. Epub ahead of print. PMID: 40767817. ↩ ↩2 ↩3 ↩4

  2. Cremer PC, Klein AL, Imazio M. Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review. JAMA. 2024;332(13):1090–1100. doi:10.1001/jama.2024.12935 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7

  3. Chiabrando JG, Bonaventura A, Vecchié A, Wohlford GF, Mauro AG, Jordan JH, Grizzard JD, Montecucco F, Berrocal DH, Brucato A, Imazio M, Abbate A. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jan 7;75(1):76-92. doi: 10.1016/j.jacc.2019.11.021. PMID: 31918837. ↩

  4. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart Journal. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318 ↩

Graph View

Backlinks