Treatment of Pericarditis

Introduction to Pericarditis Treatment

• The European Society of Cardiology recommends a stepwise approach for treating pericarditis, starting with NSAIDs (preferably ibuprofen) plus colchicine as first-line therapy, with ibuprofen 300-800mg every 6-8 hours and colchicine 0.5mg twice daily 1
• Gastrointestinal protection must be provided with NSAID therapy to prevent complications, according to the European Heart Journal 1

First-Line Therapy for Recurrent Pericarditis

• The European Society of Cardiology recommends first-line treatment for acute pericarditis with elevated inflammatory markers and trace pericardial effusion to consist of high-dose NSAIDs/aspirin plus colchicine for 3-6 months, with outpatient management for low-risk patients and follow-up evaluation after one week 2
• Idiopathic/Viral Pericarditis: treatment consists of NSAIDs/Aspirin and colchicine, with a good long-term prognosis and a recurrence rate of 15-30% without colchicine, reduced to 8-15% with colchicine 2

Second-Line and Subsequent Therapies

• Underlying causes (e.g., tuberculosis, bacterial infection, autoimmune disease) should be treated, and corticosteroids may be considered as second-line therapy when NSAIDs/colchicine are contraindicated or ineffective (Class III, Level B for first-line use) 2
• The following tapering protocol for corticosteroids is recommended:

2

• Tuberculous Pericarditis: treatment consists of anti-tuberculosis therapy plus corticosteroids, with a higher risk of constrictive pericarditis (20-30%) 2
• Bacterial Pericarditis: treatment consists of urgent drainage plus targeted antibiotics, with a high risk of constrictive pericarditis (20-30%) 2
• Neoplastic/Autoimmune Pericarditis: treatment consists of treatment of underlying cancer, with an intermediate risk of constrictive pericarditis (2-5%) 2

Treatment of Constrictive Pericarditis

• Constrictive pericarditis is characterized by impaired diastolic filling of the ventricles due to a thickened, fibrotic, and often calcified pericardium, with patients typically presenting with signs and symptoms of right heart failure, venous congestion, hepatomegaly, pleural effusions, and ascites, and preserved ventricular function in early stages 2
• The European Society of Cardiology recommends initial medical therapy for constrictive pericarditis to include diuretics, such as loop diuretics, for symptom management, with anti-inflammatory medications, including NSAIDs, colchicine, and/or corticosteroids, added when there is evidence of active inflammation 2
• Pericardiectomy remains the only definitive treatment for chronic constrictive pericarditis, with medical therapy being generally supportive and temporary, and delayed surgery associated with worse outcomes 2

Special Considerations

• Aspirin is contraindicated in children with pericarditis due to risk of Reye's syndrome, and colchicine dosing for children with pericarditis is as follows: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses 2
• During pregnancy, aspirin (low-moderate doses) is preferred during first and second trimesters, NSAIDs may be used until gestational week 20, all NSAIDs except low-dose aspirin must be withdrawn by gestational week 32, and prednisone at lowest effective doses may be used throughout pregnancy with calcium and vitamin D supplementation 2
• For cases with associated myocardial involvement (myopericarditis), the ESC recommends rest, avoidance of physical activity, and restriction of exercise for at least 6 months 2

Diagnostic Approach

• Initial workup for suspected pericarditis should include auscultation, ECG, transthoracic echocardiography, chest X-ray, and routine blood tests, including inflammatory markers, complete blood count, renal/liver function tests, and cardiac biomarkers, as recommended by the European Heart Society 2
• Laboratory tests should include complete blood count, renal function and liver tests, thyroid function, inflammatory markers (CRP and/or ESR), and cardiac biomarkers (troponins, CK) 2
• Imaging tests should include ECG to look for widespread ST-segment elevation and PR depression, and transthoracic echocardiography to assess for pericardial effusion, with ECG changes present in 25-50% of cases and pericardial effusion present in approximately 60% of cases 2
• Hospitalization is recommended for diagnosis and monitoring of acute pericarditis, with coronary angiography to rule out acute coronary syndromes and cardiac MRI to confirm myocardial involvement 2, 1
• The European Society of Cardiology indicates that pericardiocentesis is useful for diagnostic purposes in smaller effusions and is indicated for cardiac tamponade or effusions >20 mm in echocardiography 1

Monitoring and Follow-Up

• Regular echocardiographic assessment is necessary to evaluate pericardial thickness, ventricular filling patterns, and development of tamponade, guiding treatment duration and assessing response to therapy 2
• Treatment monitoring should include tracking CRP levels to guide treatment duration, assessing symptom resolution, and following ECG changes and echocardiogram findings, with tapering begun only after CRP normalization and symptom resolution, and done gradually, removing one medication class at a time, starting with NSAIDs/aspirin while maintaining colchicine for the full duration 2
• Repeat echocardiogram if symptoms worsen or new symptoms develop 2