Management of Pericarditis

Diagnosis

The European Society of Cardiology recommends that diagnosis of acute pericarditis requires at least 2 of the following 4 criteria: pericardial chest pain, pericardial friction rub, ECG changes, and pericardial effusion, which is present in approximately 60% of cases 1, 3, 4
Assessment of inflammatory markers, such as CRP, ESR, and WBC count, is recommended for diagnostic workup 4
Cardiac biomarkers, including troponin and CK, should be evaluated to identify myocardial involvement 1, 5
Transthoracic echocardiography is recommended in all suspected cases, and chest X-ray may be normal unless a large effusion is present 4

The European Society of Cardiology recommends first-line therapy consisting of aspirin (1500-3000 mg/day) or NSAIDs (ibuprofen 1200-2400 mg/day or indomethacin 75-150 mg/day) until symptom resolution, in combination with colchicine (0.5 mg twice daily or 0.5 mg once daily for patients <70 kg) for 3-6 months, and exercise restriction until symptoms resolve and CRP normalizes 1, 2, 5, 6
Second-line therapy with low-dose corticosteroids (0.25-0.5 mg/kg/day of prednisone) is recommended only when contraindications to aspirin/NSAIDs/colchicine exist, or in cases of incomplete response to first-line therapy, or when infectious causes have been excluded 2, 6
Third-line therapy with immunoglobulins, anakinra (IL-1 receptor antagonist), or azathioprine is recommended for corticosteroid-dependent cases not responsive to colchicine 2, 6
Fourth-line therapy with pericardiectomy is recommended as a last resort after thorough trial of unsuccessful medical therapy 2, 6

The American College of Cardiology recommends hospitalization for diagnosis and monitoring of myopericarditis, with similar management to pericarditis, but some authors suggest reduced NSAID dosages 1, 5, 8
Extended exercise restriction (at least 6 months from onset) is recommended for myopericarditis, along with coronary angiography to rule out acute coronary syndromes, and cardiac MRI to confirm myocardial involvement 1, 5, 7, 8
For post-MI pericarditis (Dressler's syndrome), the American College of Cardiology recommends acetaminophen for symptomatic relief, high-dose aspirin (500-1000 mg every 6-8 hours) until symptoms improve, and colchicine (0.5-0.6 mg once or twice daily) for 3 months, while avoiding NSAIDs (except aspirin) and glucocorticoids due to potential increased risk of recurrent MI, impaired myocardial healing, and rupture 8

The European Society of Cardiology recommends continuing full-dose anti-inflammatory therapy until complete symptom resolution, then gradually tapering therapies one drug at a time after CRP normalization, with colchicine continued for at least 3-6 months 2, 6
A specific tapering schedule is recommended for corticosteroids based on dose, to minimize risk of recurrence 2, 6