Pericarditis Diagnosis and Treatment

Clinical Presentation

The European Society of Cardiology notes that sharp, pleuritic chest pain that worsens when lying supine and improves when sitting forward is present in approximately 90% of pericarditis cases, and shortness of breath, especially when lying flat, is a common symptom 1, 2
Fever, malaise, and myalgia often precede other symptoms, though elderly patients may not develop fever 2
Elevated inflammatory markers (CRP, ESR, white blood cell count) are associated with pericarditis 3
Elevated cardiac biomarkers (troponins I and T, CK-MB) may indicate associated myocardial involvement (perimyocarditis) 1, 2

The European Heart Journal recommends a first-level diagnostic workup including complete blood count, renal and liver function tests, thyroid function, cardiac biomarkers (troponins, CK), ECG, transthoracic echocardiography, and chest X-ray 3
A second-level diagnostic workup may include CT and/or cardiac MRI, and pericardiocentesis or surgical drainage if cardiac tamponade is present, bacterial or neoplastic pericarditis is suspected, or moderate to large effusions are not responding to medical therapy 3

The European Society of Cardiology recommends NSAIDs as the cornerstone of treatment for acute pericarditis, with aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) for 1-2 weeks with gastroprotection, and colchicine should be added to NSAIDs as part of first-line therapy (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months to reduce risk of recurrence 4, 5
Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be considered only when NSAIDs/colchicine are contraindicated, first-line therapy has failed, or infectious causes have been excluded 4, 5

Exercise restriction is recommended until symptoms resolve and CRP, ECG, and echocardiogram normalize, and for athletes, exercise restriction should last at least 3 months 4, 5
Tuberculous pericarditis should be treated with anti-tuberculosis treatment with possible adjunctive corticosteroids 6
Purulent pericarditis should be treated with aggressive intravenous antimicrobial therapy and drainage (surgical or percutaneous) 7