Pericarditis Diagnosis and Management

Introduction

Pericarditis is a medical condition that requires prompt diagnosis and treatment, with guidelines provided by the European Society of Cardiology and the American College of Cardiology [1, @2@]

Pericarditis is diagnosed based on meeting at least 2 of the following criteria: typical chest pain, pericardial friction rub, suggestive ECG changes, and pericardial effusion on imaging, as recommended by the European Society of Cardiology 1
ECG changes alone are insufficient for diagnosis or treatment initiation, according to the European Society of Cardiology guidelines 1
C-reactive protein (CRP) elevation is essential to confirm inflammation, as stated by the European Society of Cardiology 1
The initial evaluation of pericarditis involves determining the presence of diagnostic criteria (≥2), evaluating inflammatory markers, and performing an echocardiogram to assess for effusion and rule out tamponade 1

The European Society of Cardiology guidelines recommend that patients with no symptoms and normal CRP should be observed only, while those with symptoms or elevated CRP should proceed with treatment 1
Low-risk patients can be managed as outpatients, while high-risk patients may require hospitalization if they have fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, immunosuppression, trauma, or anticoagulation therapy 1
Risk stratification is crucial, with low-risk patients managed ambulatorially with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, and high-risk patients requiring hospitalization and extended etiological investigation 1

Transthoracic echocardiography should be used to evaluate for pericardial effusion and rule out cardiac tamponade, as recommended by the European Society of Cardiology 1
Inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count with differential should be assessed to guide diagnosis and treatment 1
Renal function and liver tests should be performed to assess organ function and guide therapy options, with consideration of potential contraindications to non-steroidal anti-inflammatory drugs (NSAIDs) 1
Thyroid function tests should be done to rule out thyroid-related causes, and cardiac injury markers such as troponins and creatine kinase (CK) should be measured to identify possible myocardial involvement 1
Cardiac MRI (CMR) provides a detailed assessment of pericardial inflammation and myocardial involvement, and is recommended as a Class IIa indication for patients with high-risk features or inconclusive initial results 1
Chest CT evaluates pericardial thickness and calcification, and can be used to detect localized pericarditis missed by echocardiography 1
Pericardiocentesis is indicated for cardiac tamponade, suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large effusions not responding to medical therapy, with analysis including culture for bacteria, fungi, and mycobacteria, cytology, and PCR for infectious agents 1, 2

High-risk features include fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, immunosuppression, trauma, or anticoagulation therapy 1
The European Society of Cardiology classifies pericarditis into categories including acute, incessant, recurrent, and chronic, with complications such as cardiac tamponade and constrictive pericarditis determining clinical severity 1

The ESC defines pericarditis categories as:

Category	Description
Acute	First episode
Incessant	Lasting >4-6 weeks but <3 months without remission
Recurrent	New episode after a symptom-free interval of 4-6 weeks or more
Chronic	Lasting >3 months

The American College of Cardiology recommends treatment with NSAIDs (e.g., ibuprofen 600mg every 8 hours for 1-2 weeks) and colchicine (0.5mg twice daily for ≥70kg or once daily for <70kg) for 3 months, with gastroprotection [1, @2@]
Corticosteroids (e.g., prednisone 0.2-0.5mg/kg/day) are recommended only in cases of failure of NSAID/colchicine treatment, contraindications to NSAIDs, or specific indications [@2@, 1]
Gastroprotection should always be provided with NSAIDs, as recommended by the European Society of Cardiology 1
Aspirin can be used at a dose of 750-1000mg every 8 hours for 1-2 weeks, then taper by 250-500mg every 1-2 weeks, or ibuprofen at 600mg every 8 hours for 1-2 weeks, then taper by 200-400mg every 1-2 weeks, always providing gastroprotection 1

Cardiac tamponade is rare in idiopathic pericarditis but common in specific etiologies such as neoplasia, tuberculosis, or purulent pericarditis, and constrictive pericarditis occurs in <1% of patients with idiopathic pericarditis but up to 20-30% of cases of bacterial pericarditis [@4@, 1]
Purulent pericarditis is almost always fatal if left untreated, with a mortality rate of 40% even with treatment 1
Corticosteroids should be avoided as first-line treatment due to their association with a higher risk of recurrences 1
Tuberculous pericarditis requires specific antituberculous treatment and has a mortality rate close to 85% without treatment 1

The disease course can be classified as acute (first episode), incessant (lasting >4-6 weeks but <3 months without remission), recurrent (new episode after an interval of 4-6 weeks or more without symptoms), or chronic (lasting >3 months) [@3@, 1]

Follow-up evaluation should include control at 1 week to assess response to treatment, use of CRP to guide treatment duration and evaluate response, echocardiographic follow-up to monitor resolution of effusion, restriction of physical activity until resolution of symptoms and normalization of inflammatory markers, and avoidance of competitive sports for at least 3 months in athletes [@5@, 1]
Patients with pericarditis can be managed as outpatients with empiric anti-inflammatories, with follow-up after 1 week to assess treatment response, and CRP should be used to guide treatment duration and assess response 1