Acute Pericarditis Diagnosis and Treatment

Diagnostic Criteria

The European Society of Cardiology recommends that diagnosis of acute pericarditis requires at least 2 of the following 4 criteria: pericarditic chest pain, pericardial friction rub, ECG changes, and pericardial effusion 1, 2
Pericarditic chest pain is characterized by retrosternal or left precordial, sharp, pleuritic pain that radiates to the trapezius ridge and varies with posture (improves when sitting forward) 1, 2
Pericardial friction rub is a mono-, bi-, or triphasic sound on auscultation, which can be transient and is present in <30% of cases 2, 3
ECG changes include new widespread ST-segment elevation (concave upward) and PR-segment depression, occurring in 25-50% of cases 1
Pericardial effusion is a new or worsening effusion seen on echocardiography 1, 3

High-risk features requiring hospital admission include high fever (>38°C/100.4°F) 3, subacute onset (symptoms developing over several days) 3, large pericardial effusion (>20 mm on echocardiography) 3, cardiac tamponade 3, failure to respond to NSAIDs within 7 days 3, and elevated cardiac biomarkers suggesting myopericarditis 1, 3

The European Society of Cardiology recommends first-line treatment with NSAIDs at full anti-inflammatory doses until symptom resolution 1, 4
Colchicine (0.5 mg twice daily or 0.5 mg daily for patients <70 kg) for 3 months to reduce recurrence risk 4
Exercise restriction until symptom resolution and CRP normalization 4
Follow-up evaluation after 1 week to assess treatment response 1
Low-dose corticosteroids (only if contraindications to NSAIDs/colchicine exist or after excluding infectious causes) 1, 4

Avoid glucocorticoids as first-line therapy, as they increase risk of recurrence and should be reserved for specific indications 4, 5
Avoid NSAIDs in post-myocardial infarction pericarditis, as they may impair myocardial healing 5, 6
Echocardiography is essential to detect effusion and evaluate for complications 1
Taper medications gradually, only after symptoms resolve and CRP normalizes 4
Differentiate from acute coronary syndrome, as ECG in pericarditis shows widespread ST elevation without reciprocal changes 1