Ryan Nowrouzi MD, Ravi K. Ghanta MD
Baylor College of Medicine
August 31st, 2024
Abbreviations & Definitions
CRP – C-reactive protein
ESR – Erythrocyte sedimentation rate
NSAID – Nonsteroidal anti-inflammatory drug
PPS – Postpericardiectomy syndrome
Indications & Guidelines for Management by Grade/Stage of Disease
Pericarditis is defined as the inflammation of the pericardium, the two-layered fibroserous sac that encases the heart. The etiology of pericarditis is widely varied, however, the most common causes in North America are viral or idiopathic. Classical presentation of pericarditis involves pleuritic chest pain that is worsened with inspiration or lying down and made better with leaning forward. On auscultation, a pericardial friction rub is characteristic.1
Diagnosis of pericarditis remains a clinically established one. The main accepted international guidelines surrounding the diagnosis and treatment of pericarditis were published in 2015 by the European Society of Cardiology.2 In these guidelines, at least two of the four criteria must be met to reach a diagnosis (Table 1). Pericardial chest pain, auscultation of a pericardial friction rub, EKG changes, namely widespread ST elevations across multiple or all leads, and pericardial effusion are characteristic criteria. Laboratory markers, including elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), while not part of diagnostic criteria, are a common occurrence and supportive finding in patients with suspected pericarditis.
Table 1. Diagnostic Criteria for Acute Pericarditis.
| Acute Pericarditis | Pericardial chest pain Auscultation of pericardial friction rub New, widespread ST-elevation or PR depression on EKG New or worsening pericardial effusion |
|---|
Other forms of pericarditis are classified in the guidelines based on the timeline of symptom burden. Incessant pericarditis is pericarditis spanning >4-6 weeks but <3 months without remission. Recurrent pericarditis is defined as recurrence after a documented symptom-free interval of at least 4-6 weeks after the initial episode. Chronic pericarditis is defined as pericarditis lasting >3 months.
Treatment
The treatment for pericarditis is largely guided by the presumed etiology of the disease. In patients with an established cause of pericarditis not attributable to viral or post-pericardiectomy, specific medical therapy should be utilized, such as the use of antibiotics for bacterial pericarditis. Given that the most common etiology is viral or idiopathic, the disease is treated as an inflammatory one, and appropriate anti-inflammatory agents are used, including aspirin, NSAIDS, and colchicine (Table 2). The use of NSAIDS, namely ibuprofen, for the treatment of acute pericarditis is mainly based on clinical experience, as no randomized clinical trials have confirmed their efficacy.3 The use of these agents should be weighed with patient-level factors and risks, including kidney injury or gastrointestinal bleeding. The efficacy of colchicine as treatment for both acute and recurrent pericarditis has been well established in the literature.4 Aspirin is frequently favored in patients undergoing treatment with concomitant coronary artery disease.
Low-dose corticosteroids have been used as second-line agents in patients who cannot tolerate or have contraindications to first-line modalities. Although in retrospective studies it has been shown that these medicines have higher recurrence rates and a prolonged disease course.3
Postpericardiectomy syndrome (PPS) represents a unique, autoimmune cause of pericarditis wherein the inflammation of the pericardium is secondary to damage or division of the pericardium in cardiac surgery. It is estimated to occur in up to one-third of patients who undergo cardiac surgery. While the common treatment strategies for pericarditis listed in Table 2 are commonly used with good results, two randomized controlled trials have shown that colchicine prophylaxis in high-risk patients for PPS can decrease both the incidence of PPS as well as pericardial effusions.
Table 2. Common Treatment Regimens for Acute Inflammatory Pericarditis.
| Drug | Dosing | Treatment Duration | Tapering Phase |
|---|---|---|---|
| Aspirin | 750-1000 mg Q8hours | 1-2 weeks | Drop dose by 250-500 mg every 1-2 weeks |
| Ibuprofen | 600 mg Q8hours | 1-2 weeks | Drop dose by 200-400 mg every 1-2 weeks |
| Colchicine | 0.5 mg once (BID if >70 kg) | 3 months | Not mandatory, can space to every other day in last weeks |
| Prednisone (second-line agent) | 0.2-0.5 mg/kg daily | Months | Slow taper over multiple weeks once symptoms resolve |
Constrictive Pericarditis
The disease process of constrictive pericarditis is highlighted by inflammation of the pericardium, which can then, in turn, lead to stiffening of the pericardium. The consequence of this stiffening includes impaired diastolic filling, which is characteristic of the disease. The most common etiology of this, as in acute pericarditis, is viral or idiopathic. Treatment of this condition varies based on the presence or absence of active inflammation. In the case of active inflammation, treatment with a course of anti-inflammatory medications, as in Table 2, is indicated. In cases where inflammation is not suspected, surgical intervention with pericardiectomy is the primary treatment modality in carefully selected patients, although not without significant risk.5
Table 3. Summary Table of Pericarditis Etiology and Treatment.
| Pericarditis Type | Incidence | Treatment | Evidence |
|---|---|---|---|
| Bacterial | Rare, <5% of all cases in developed countries | Antibiotics | 2,4 |
| Viral | Common, ~90% of all cases | Anti-inflammatory agents as first line, see Table 2 | 1,2 |
| Autoimmune | Rare, ~2-7% of all cases | Anti-inflammatory agents as first line, see Table 2 | 1,2 |
| Postpericardiectomy syndrome | Common, up to 1/3 of all patients undergoing cardiac surgery | Anti-inflammatory agents as first line, see Table 2 | 1,2 |
| Constrictive | Rare, <0.5% of patients with viral pericarditis | Anti-inflammatory agents when inflammation suspected. Pericardiectomy in noninflammatory cases | 2,5 |
Supporting Evidence for Current Indications & Guidelines
Yehuda Adler, Philippe Charron, Massimo Imazio, Luigi Badano, Gonzalo Barón-Esquivias, Jan Bogaert, Antonio Brucato, Pascal Gueret, Karin Klingel, Christos Lionis, Bernhard Maisch, Bongani Mayosi, Alain Pavie, Arsen D Ristić, Manel Sabaté Tenas, Petar Seferovic, Karl Swedberg, Witold Tomkowski, ESC Scientific Document Group, 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC).
This source is the 2015 guideline document set forth by the ESC, which was used to produce this chapter. Overall, the ESC guidelines emphasize a tailored approach to the management of pericardial diseases, considering the underlying etiology, hemodynamic impact, and individual patient characteristics.
Ongoing Trials/Recent Publications
Melendo-Viu M, Marchán-Lopez Á, Guarch CJ, Roubín SR, Abu-Assi E, Meneses RT, Ynsaurriaga FA, Hernandez AV, Bueno H. A systematic review and meta-analysis of randomized controlled trials evaluating pharmacologic therapies for acute and recurrent pericarditis. Trends Cardiovasc Med. 2023 Jul;33(5):319-326. doi: 10.1016/j.tcm.2022.02.001. Epub 2022 Feb 5. PMID: 35131416.
This source is a recent meta-analysis published in 2022, looking at patients with acute and recurrent pericarditis. This meta-analysis includes six randomized controlled trials involving 914 patients treated with colchicine plus NSAIDs and one randomized controlled trial involving 21 patients treated with anakinra. A key takeaway from the study is that colchicine plus NSAIDs is the most effective first-line therapy for reducing recurrences in acute and recurrent pericarditis.
Sources
- Dary C, Yang R, Smith J, Mokadam NA. Pericardial Disease. In: Baumgartner WA, Jacobs JP, Meyerson S, eds. Adult and Pediatric Cardiac Surgery. STS Cardiothoracic Surgery E-Book. Chicago: Society of Thoracic Surgeons; 2024. ebook.sts.org. Accessed December 21, 2024.
- Yehuda Adler, Philippe Charron, Massimo Imazio, Luigi Badano, Gonzalo Barón-Esquivias, Jan Bogaert, Antonio Brucato, Pascal Gueret, Karin Klingel, Christos Lionis, Bernhard Maisch, Bongani Mayosi, Alain Pavie, Arsen D Ristić, Manel Sabaté Tenas, Petar Seferovic, Karl Swedberg, Witold Tomkowski, ESC Scientific Document Group , 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)
- Melendo-Viu M, Marchán-Lopez Á, Guarch CJ, Roubín SR, Abu-Assi E, Meneses RT, Ynsaurriaga FA, Hernandez AV, Bueno H. A systematic review and meta-analysis of randomized controlled trials evaluating pharmacologic therapies for acute and recurrent pericarditis. Trends Cardiovasc Med. 2023 Jul;33(5):319-326. doi: 10.1016/j.tcm.2022.02.001. Epub 2022 Feb 5. PMID: 35131416.
- Chiabrando, J, Bonaventura, A, Vecchié, A. et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. JACC. 2020 Jan, 75 (1) 76–92.
- Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation 2011;124:1270-5.
