Pericarditis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected pericarditis

1st line – triage and consider admission to hospital

Back

1st line –

triage and consider admission to hospital

Organise admission to hospital for any patient with:

A clinical presentation that suggests an underlying aetiology requiring inpatient management[1]
Any of the following high-risk features:[1]
- Major risk factors (associated with poor prognosis after multivariate analysis):
  - High fever (i.e., >38°C [>100.4°F])
  - Subacute course (i.e., symptoms over several days without a clear-cut acute onset)
  - Evidence of a large pericardial effusion (i.e., diastolic echo-free space >20 mm)
  - Cardiac tamponade
  - Failure to respond within 7 days to a non-steroidal anti-inflammatory drug
- Minor risk factors (based on expert opinion and literature review)
  - Pericarditis associated with myocarditis (myopericarditis; associated with a rise in troponin)
  - Immunosuppression
  - Trauma
  - Oral anticoagulant therapy.

Ensure a patient with any of these high-risk features has investigation of the underlying cause, as well as careful observation and follow-up.[1]

Otherwise, if the patient does not have any high-risk features or a clinical presentation that suggests an underlying aetiology requiring inpatient management, consider outpatient management. Start treatment (i.e., empirical anti-inflammatories) and arrange follow-up after 1 week to assess the response to treatment.[1]

Consider – pericardiocentesis

ACUTE

idiopathic or viral (non-purulent)

1st line – non-steroidal anti-inflammatory drug (NSAID)

Back

1st line –

non-steroidal anti-inflammatory drug (NSAID)

Start an NSAID (as long as there are no contraindications) immediately after diagnosis for symptom management.[1]

To guide treatment duration, evaluate the patient’s symptoms and their C-reactive protein levels. In general, for a patient with uncomplicated pericarditis, continue the NSAID at the initial dose for 1 to 2 weeks before tapering gradually.
Practical tip
A common error is to taper the NSAID too quickly, which can result in recurrence of symptoms.
Choice of drug is based on patient characteristics (e.g., contraindications, previous efficacy, or side effects), presence of concomitant diseases (e.g., favour aspirin over other NSAIDs if antiplatelet therapy is required), and physician expertise.[1][18]
Practical tip
Aspirin is preferred for patients developing pericarditis after a myocardial infarction, as other NSAIDs adversely affect myocardial healing and are associated with increased risk of future cardiac events.[58] If high-dose aspirin is not effective, consider paracetamol or an opioid analgesic.
NSAIDs reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.

Primary options

aspirin: 750-1000 mg orally every 8 hours for 1-2 weeks, then decrease by 250-500 mg/dose every 1-2 weeks

ibuprofen: 600 mg orally every 8 hours for 1-2 weeks, then decrease by 200-400 mg/dose every 1-2 weeks

Plus – proton-pump inhibitor

Plus – colchicine

Back

Plus –

colchicine

Treatment recommended for ALL patients in selected patient group

If the patient has idiopathic or viral pericarditis, add colchicine and continue it for 3 months.[20][59][60]

Colchicine is crucial to prevent recurrent pericarditis, improve response, and increase remission rates.[1]
Order a baseline full blood count before starting treatment because colchicine may cause neutropenia and bone marrow suppression.
Use colchicine with caution in patients with renal and hepatic impairment because it may be contraindicated with certain medications. A dose reduction may be required.
In practice, avoid colchicine where possible in patients who are very frail or have impaired mobility, due to the high likelihood of treatment-related diarrhoea.
While tapering the dose is not mandatory, consider doing so in the last few weeks of treatment to prevent persistence of symptoms and recurrence.[1]

Practical tip

Warn the patient that colchicine may cause gastrointestinal side effects such as diarrhoea.[62] Gradually increase the dose until onset of side effects. Consider reducing the dose if the patient is unable to tolerate the drug at full initial dose.[63]

Primary options

colchicine: <70 kg body weight: 0.5 mg orally once daily for 3 months, then may taper to 0.5 mg once daily on alternate days in the last weeks; ≥70 kg body weight: 0.5 mg orally twice daily for 3 months, then may taper to 0.5 mg once daily in the last weeks

Plus – exercise restriction

Consider – corticosteroid

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Only consider using a low-dose corticosteroid with specialist guidance from a rheumatologist and a cardiologist.

A corticosteroid is an appropriate option for a small proportion of patients, specifically if:
- An infectious cause has been excluded and there is failure of, or contraindication to, NSAIDs and/or colchicine[1]
- There is a specific indication for use (e.g., the presence of an autoimmune disease). Corticosteroids are used in combination with colchicine in this scenario.[1]

Do not use corticosteroids in a patient with viral pericarditis because of the risk of re-activation of the viral infection and ongoing inflammation.

Use corticosteroids at low to moderate doses.[18] Continue with the initial dose until symptoms have resolved and the patient’s C-reactive protein level has normalised. Once this is achieved, taper the dose gradually.[1]

Primary options

prednisolone: 0.2 to 0.5 mg/kg/day orally until resolution of symptoms, then gradually taper according to local protocols

not idiopathic or viral (non-purulent)

1st line – treatment of the underlying cause

Back

1st line –

treatment of the underlying cause

Treat the underlying cause if known. Pericarditis can be caused by:

Tuberculosis (a common cause in the developing world)
- See Extrapulmonary tuberculosis
Secondary immune processes (e.g., rheumatic fever, post-cardiotomy syndrome, post-myocardial infarction syndrome)
Metabolic disorders (e.g., uraemia, myxoedema), radiotherapy
Cardiac surgery
Percutaneous cardiac interventions
Systemic autoimmune disorders (e.g., rheumatoid arthritis, systemic sclerosis, reactive arthritis, familial Mediterranean fever, systemic vasculitides, inflammatory bowel disease)
Bacterial/fungal/parasitic infections
Trauma
Certain drugs (e.g., hydralazine, antineoplastic drugs, clozapine, tumour necrosis factor-alpha inhibitors, phenytoin)[1]
Neoplasms.

Seek specialist advice as needed.

If the patient has tuberculous pericarditis, first-line treatment is 4 to 6 weeks of antituberculous therapy.[1]
- When tuberculous pericarditis is confirmed in a non-endemic area, a suitable 6-month regimen is effective; empirical therapy is not required in the absence of an established diagnosis in non-endemic areas.[1]
- Adjunctive therapy with corticosteroids and immunotherapy has not been shown to be beneficial.[66] However, corticosteroids may be considered for a patient with tuberculous pericarditis who is HIV-negative.[68] [ ]
- Pericardiectomy is recommended if the patient does not improve or is deteriorating after 4 to 8 weeks of antituberculosis therapy.[1]
Most patients with uraemic pericarditis respond to intensive dialysis within 1 to 2 weeks.
Autoimmune disorders are treated with corticosteroids and/or another immunosuppressive therapy depending on the specific condition.
Treatment of neoplasms may involve any combination of radiotherapy, chemotherapy, or surgery depending on the type of tumour identified.[1][39][40]

Plus – non-steroidal anti-inflammatory drug (NSAID)

Back

Plus –

non-steroidal anti-inflammatory drug (NSAID)

Treatment recommended for ALL patients in selected patient group

Start an NSAID (as long as there are no contraindications) immediately after diagnosis for symptom management.[1]

To guide treatment duration, evaluate the patient’s symptoms and their C-reactive protein levels. In general, for a patient with uncomplicated pericarditis, continue the NSAID at the initial dose for 1 to 2 weeks before tapering gradually.
Practical tip
A common error is to taper the NSAID too quickly, which can result in recurrence of symptoms.
Choice of drug is based on patient characteristics (e.g., contraindications, previous efficacy, or side effects), presence of concomitant diseases (e.g., favour aspirin over other NSAIDs if antiplatelet therapy is required), and physician expertise.[1][18]
Practical tip
Aspirin is preferred for patients developing pericarditis after a myocardial infarction, as other NSAIDs adversely affect myocardial healing and are associated with increased risk of future cardiac events.[58] If high-dose aspirin is not effective, consider paracetamol or an opioid analgesic.
NSAIDs reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.

Primary options

aspirin: 750-1000 mg orally every 8 hours for 1-2 weeks, then decrease by 250-500 mg/dose every 1-2 weeks

ibuprofen: 600 mg orally every 8 hours for 1-2 weeks, then decrease by 200-400 mg/dose every 1-2 weeks

Plus – proton-pump inhibitor

Plus – colchicine (unless the patient has TB pericarditis)

Back

Plus –

colchicine (unless the patient has TB pericarditis)

Treatment recommended for ALL patients in selected patient group

Add colchicine, unless the patient has tuberculosis pericarditis.[1][20][59][60][61] See Treatment of the underlying cause above. Continue colchicine for 3 months.[1][20][59][60]

Colchicine is crucial to prevent recurrent pericarditis, improve response, and increase remission rates.[1]
Order a baseline full blood count before starting treatment because colchicine may cause neutropenia and bone marrow suppression.
Use colchicine with caution in patients with renal and hepatic impairment because it may be contraindicated with certain medications. A dose reduction may be required.
In practice, avoid colchicine where possible in patients who are very frail or have impaired mobility, due to the high likelihood of treatment-related diarrhoea.
While tapering the dose is not mandatory, consider doing so in the last few weeks of treatment to prevent persistence of symptoms and recurrence.[1]

Practical tip

Primary options

Consider – corticosteroid

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Only consider using a low-dose corticosteroid with specialist guidance from a rheumatologist and a cardiologist.

A corticosteroid is an appropriate option for a small proportion of patients, specifically if:
- An infectious cause has been excluded and there is failure of, or contraindication to, NSAIDs and/or colchicine[1]
- There is a specific indication for use (e.g., the presence of an autoimmune disease). Corticosteroids are used in combination with colchicine in this scenario.[1]

Primary options

prednisolone: 0.2 to 0.5 mg/kg/day orally until resolution of symptoms, then gradually taper according to local protocols

Plus – exercise restriction

purulent

1st line – intravenous antibiotic therapy

Plus – specialist management

ONGOING

recurrent disease

1st line – non-steroidal anti-inflammatory drug (NSAID)

Back

1st line –

non-steroidal anti-inflammatory drug (NSAID)

Start an NSAID immediately after diagnosis for symptom management.

Choice of drug is based on patient characteristics (e.g., contraindications, previous efficacy, or side effects), the presence of concomitant diseases (e.g., aspirin is favoured over other NSAIDs if antiplatelet therapy is required), and physician expertise.[18]
Practical tip
Aspirin is the preferred NSAID for patients developing pericarditis after a myocardial infarction, or if ischaemic heart disease is a concern.[1][39][40]
Continue treatment until symptoms resolve and C-reactive protein has settled.[1] Taper drug therapy gradually according to the patient’s symptoms and their C-reactive protein level.[1]
NSAIDs reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.[39][40]

Primary options

aspirin: 750-1000 mg orally every 8 hours for 1-2 weeks, then decrease by 250-500 mg/dose every 1-2 weeks

ibuprofen: 600 mg orally every 8 hours for 1-2 weeks, then decrease by 200-400 mg/dose every 1-2 weeks

Plus – proton-pump inhibitor

Plus – colchicine (unless the patient has TB pericarditis)

Back

Plus –

colchicine (unless the patient has TB pericarditis)

Treatment recommended for ALL patients in selected patient group

Add colchicine, unless the patient has tuberculosis pericarditis.[1][61] Continue colchicine for 6 months in patients with recurrent disease.[1]

Colchicine is crucial to reduce recurrences, improve response, and increase remission rates.[1]
If indicated, consider a longer duration of treatment with colchicine according to the patient’s clinical response.[1]
Use colchicine with caution in patients with renal and hepatic impairment because it may be contraindicated with certain medications. A dose reduction may be required.
In practice, avoid colchicine where possible in patients who are very frail or have impaired mobility, due to the high likelihood of treatment-related diarrhoea.
Before commencing treatment, order a baseline full blood count because colchicine may cause neutropenia and bone marrow suppression.

Primary options

Plus – treatment of the underlying cause

Back

Plus –

treatment of the underlying cause

Treatment recommended for ALL patients in selected patient group

Treat the underlying cause if known. Pericarditis can be caused by:

Tuberculosis (a common cause in the developing world)
- See Extrapulmonary tuberculosis
Secondary immune processes (e.g., rheumatic fever, post-cardiotomy syndrome, post-myocardial infarction syndrome)
Metabolic disorders (e.g., uraemia, myxoedema), radiotherapy
Cardiac surgery
Percutaneous cardiac interventions
Systemic autoimmune disorders (e.g., rheumatoid arthritis, systemic sclerosis, reactive arthritis, familial Mediterranean fever, systemic vasculitides, inflammatory bowel disease)
Bacterial/fungal/parasitic infections
Trauma
Certain drugs (e.g., hydralazine, antineoplastic drugs, clozapine, tumour necrosis factor-alpha inhibitors, phenytoin)[1]
Neoplasms.

Seek specialist advice as needed.

If the patient has tuberculous pericarditis, first-line treatment is 4 to 6 weeks of antituberculous therapy.[1]
- When tuberculous pericarditis is confirmed in a non-endemic area, a suitable 6-month regimen is effective; empirical therapy is not required in the absence of an established diagnosis in non-endemic areas.[1]
- Adjunctive therapy with corticosteroids and immunotherapy has not been shown to be beneficial.[66] However, corticosteroids may be considered for a patient with tuberculous pericarditis who is HIV-negative.[68] [ ]
- Pericardiectomy is recommended if the patient does not improve or is deteriorating after 4 to 8 weeks of antituberculosis therapy.[1]
Most patients with uraemic pericarditis respond to intensive dialysis within 1 to 2 weeks.
Autoimmune disorders are treated with corticosteroids and/or another immunosuppressive therapy depending on the specific condition.
Patients developing pericarditis after a myocardial infarction are treated with high-dose aspirin.[1] If high-dose aspirin is not effective, paracetamol or an opioid analgesic should be considered.[58]
Treatment of neoplasms may involve any combination of radiotherapy, chemotherapy, or surgery depending on the type of tumour identified.[1][39][40]

Plus – exercise restriction

Consider – corticosteroid

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

If the patient does not respond completely to an NSAID plus colchicine, revisit the diagnosis of pericarditis and ensure other causes are ruled out. If there is ongoing inflammation on computed tomography/magnetic resonance imaging, seek advice from a rheumatologist to consider adding a corticosteroid at a low to moderate dose.[1]

Avoid corticosteroids if infections, particularly bacterial infections and tuberculosis, cannot be excluded.[1]
In general, restrict corticosteroid use to patients with specific indications (including systemic inflammatory diseases, post-cardiotomy syndromes, and pregnancy), NSAID contraindications (true allergy, recent peptic ulcer or gastrointestinal bleeding, oral anticoagulant therapy when the bleeding risk is considered high or unacceptable) or intolerance, or persistent disease despite appropriate doses.[1]

Continue the initial dose until symptoms have resolved and the C-reactive protein level has normalised. Once this is achieved, taper the dose gradually.[1]

Primary options

prednisolone: 0.2 to 0.5 mg/kg/day orally until resolution of symptoms, then gradually taper according to local protocols

Consider – immunosuppressant

Back

Consider –

immunosuppressant

Additional treatment recommended for SOME patients in selected patient group

Alternative therapies for recurrent pericarditis are immunosuppressants – including intravenous immunoglobulin, interleukin-1 inhibitors (e.g., anakinra), and azathioprine – but these should only be started by a rheumatologist.[1][20][59][69][70][71][72][73][74][75]

Primary options

azathioprine: consult specialist for guidance on dose

anakinra: consult specialist for guidance on dose

normal immunoglobulin human: consult specialist for guidance on dose

Consider – pericardiectomy

Back

Consider –

pericardiectomy

Additional treatment recommended for SOME patients in selected patient group

Pericardiectomy can be considered if the patient has persistent symptomatic recurrent pericarditis (particularly where constriction is present, e.g., following cardiac surgery or radiotherapy), but is a significant and invasive procedure which should be carried out only after careful consideration by the multidisciplinary team including a full evaluation of risks and benefits.[1][53][76] Operative mortality is high.[77]

Pericardiectomy is also indicated if a patient has tuberculous pericarditis with recurrent effusions or evidence of constrictive physiology despite medical therapy.[3] See Extrapulmonary tuberculosis.

Pericardiectomy is particularly recommended if the patient’s condition is not improving or is deteriorating after 4 to 8 weeks of antituberculosis therapy.
Standard antituberculosis drugs for 6 months are recommended for the prevention of tuberculous pericardial constriction.[1]

[Figure caption and citation for the preceding image starts]: Pericardiectomy in a 56-year-old male patient with idiopathic calcific constrictive pericarditis. The pericardium is thickened and calcifiedPatanwala I, Crilley J, Trewby PN. BMJ Case Reports 2009; doi:10.1136/bcr.06.2008.0015 [Citation ends].

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Pericarditis

Treatment algorithm

suspected pericarditis

triage and consider admission to hospital

pericardiocentesis

idiopathic or viral (non-purulent)

non-steroidal anti-inflammatory drug (NSAID)

Practical tip

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

proton-pump inhibitor

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

colchicine

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

exercise restriction

corticosteroid

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

not idiopathic or viral (non-purulent)

treatment of the underlying cause

non-steroidal anti-inflammatory drug (NSAID)

Practical tip

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

proton-pump inhibitor

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

colchicine (unless the patient has TB pericarditis)

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

corticosteroid

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

exercise restriction

purulent

intravenous antibiotic therapy

specialist management

recurrent disease

non-steroidal anti-inflammatory drug (NSAID)

Practical tip

Primary options

proton-pump inhibitor

Primary options

colchicine (unless the patient has TB pericarditis)

Primary options

treatment of the underlying cause

exercise restriction

corticosteroid

Primary options

immunosuppressant