Pericarditis

Samuel Heery

Background

Inflammation of the pericardial sac. Classification: acute (≤4-6 weeks), recurrent (symptom-free interval ≥4-6 weeks), incessant (>4-6 weeks without remission), chronic (>3 months).

Etiologies

Idiopathic/viral (80-90%): Coxsackievirus, adenovirus, COVID-19, EBV, parvovirus B19. Other: bacterial (TB, staph, strep), fungal, malignancy, autoimmune (SLE, RA, sarcoidosis), post-MI (Dressler syndrome), myocarditis, post-pericardiotomy, trauma, uremia, drug-induced.

Diagnosis

2025 ACC criteria require pleuritic chest pain (mandatory) PLUS ≥1 additional finding:

  • Pericardial friction rub (30%), ECG changes (diffuse ST elevation/PR depression, 25-60%), elevated inflammatory markers (CRP, ESR), new/worsening pericardial effusion (≤60%), or pericardial inflammation on CMR/CT.
  • Zero additional findings = unlikely; 1 = possible; ≥2 = definite diagnosis. Concomitant myocarditis occurs in 15%.

Evaluation

  • All patients: ECG, chest x-ray, CBC, BMP, troponin, ESR, CRP, TTE.
  • Urgent TTE if tamponade suspected.
  • Cardiac MR recommended for complicated/recurrent/incessant cases.
  • Additional testing if indicated: blood cultures, ANA, RF, anti-CCP, PPD, chest CT.

Treatment

First-line (all patients):

  • NSAIDs: Ibuprofen 600-800 mg TID OR aspirin 650-1000 mg TID (preferred post-MI/CAD).
  • PLUS Colchicine 0.5-0.6 mg BID (if >70 kg) or daily (if ≤70 kg).
  • Duration: NSAIDs tapered after symptom resolution and CRP normalization (typically 1-2 weeks); Colchicine for 3 months (acute), ≥6 months (first recurrence)
  • Add PPI for gastric protection.

Efficacy:

  • Colchicine reduces recurrence from 37.5% to 16.7% (NNT=5).
  • Recurrence after first episode: 15-30%; after first recurrence: 50%.

Second-line (failure/intolerance to NSAIDs + colchicine):

  • For inflammatory phenotype (fever, CRP >10 mg/L, or CMR inflammation):
    • Preferred: Anti-IL-1 agents (anakinra, rilonacept, goflikicept).
    • Reduces recurrence from 74-90% to 6.7-18%
    • Screen for hepatitis, HIV, TB before initiating.
    • Duration uncertain; 50-75% recur upon discontinuation.

For non-inflammatory phenotype or contraindications to IL-1 blockers:

  • Prednisone 0.2-0.5 mg/kg/day (avoid 1.0 mg/kg).
  • Maintain until remission, then slow taper over months.
  • Consider PJP/osteoporosis prophylaxis if >20 mg for >1 month.

Specific indications for corticosteroids:

  • When NSAIDs contraindicated (severe renal failure, anticoagulation, pregnancy >20 weeks), autoimmune disease requiring steroids, post-cardiac surgery unresponsive to colchicine, tuberculous constrictive pericarditis.

Third-line (refractory):

  • Azathioprine, IVIG, pericardiectomy at high-volume centers (last resort).

Activity Restriction

  • Exercise restriction ≥1 month until clinical remission (maintain HR 100 bpm with activity). Tachycardia increases pericardial friction and inflammation.

Prognosis/Recurrence

  • Constrictive pericarditis: 0.5%; tamponade: 3%. Most recurrences occur within 3-6 months.
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