Recommendations

Key Recommendations

Treatment is directed at any identified underlying disorder with supportive management directed at relief of symptoms. Hospitalization is generally recommended to determine etiology where possible, observe for complications such as cardiac tamponade, and gauge response to therapy.

Initial management of patients with suspected pericarditis

Any patient with a clinical presentation that suggests an underlying etiology should be admitted to hospital for further investigation and treatment.[1]

Patients with at least one predictor of poor prognosis (major or minor risk factors below) should also be admitted.[1]

Major risk factors:

  • High fever (i.e., >100.4°F [>38°C])

  • 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 nonsteroidal anti-inflammatory drug (NSAID).

Minor risk factors:

  • Pericarditis associated with myocarditis (myopericarditis)

  • Immunosuppression

  • Trauma

  • Oral anticoagulant therapy.

Patients with any of these risk factors warrant careful observation and follow-up. Some patients without any of these features can be managed as an outpatient if considered appropriate. In these cases, the patient should be started on treatment (i.e., empiric anti-inflammatories) with follow-up after 1 week to assess the response to treatment.[1]

Pericardial effusion

If a pericardial effusion is present, pericardiocentesis is indicated for clinical tamponade, for high suspicion of purulent or neoplastic pericarditis, or if the effusion is large or symptomatic.[1] In the absence of these indications, medical therapy is started as dictated by the cause.

Purulent disease

Purulent pericarditis is immediately life-threatening and requires immediate confirmation of diagnosis via urgent pericardiocentesis. Pericardial fluid should be tested for bacterial, fungal, and tuberculous causes, and blood should be drawn for culture.[1]

If purulent pericarditis is suspected, urgent percutaneous pericardiocentesis with rinsing of the pericardial cavity and intravenous antibiotics are mandatory. Empiric intravenous antibiotic therapy is recommended until microbiologic results are available.[1] There are limited data available to guide antibiotic selection, but experts typically recommend a regimen that contains an antistaphylococcal antibiotic. The choice of antibiotics will depend on various factors including local resistance patterns and MRSA prevalence. Follow your local protocols and seek microbiology or infectious disease advice. Empiric therapy should be switched to tailored therapy depending on the underlying pathogens identified from pericardial fluid and blood cultures.[1]

Therapy with systemic antibiotics should be continued until fever and clinical signs of infection, including leukocytosis, have resolved.[3]

An NSAID should also be started on diagnosis for symptom management with a proton-pump inhibitor to reduce gastrointestinal adverse effects; the dose should be tapered after 1-2 weeks according to symptoms.[1][14] Acetaminophen or an opioid can be considered if NSAIDs are not effective or are contraindicated. Colchicine should only be used with caution in patients with purulent pericarditis as it may interfere with leukocyte function and infection clearance.[54]

Open surgical drainage via a subxiphoid pericardiotomy is also required.[1] Pericardiectomy in these patients is necessary in the presence of dense adhesions or loculations, persistent bacteremia, recurrent tamponade, or progression to constrictive physiology.[1][37][Figure caption and citation for the preceding image starts]: Open surgery in a baby with purulent pericarditis; the abscess is indicated by the arrowKaruppaswamy V, Shauq A, Alphonso N. BMJ Case Reports 2009; doi:10.1136/bcr.2007.136564 [Citation ends].Open surgery in a baby with purulent pericarditis; the abscess is indicated by the arrow

Exercise should be restricted until chest pain resolves and inflammatory markers have normalized.[55]​ A minimum of 3 months is often considered appropriate (and recommended for patients involved in competitive sports), but shorter periods of exercise restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

Nonpurulent disease: first presentation

NSAIDs are given for symptom relief.[16][20][37][57]​ They reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.[37][38]​ NSAIDs are given with a proton-pump inhibitor to decrease the risk of gastrointestinal adverse effects (e.g., ulcer formation); consider tapering the dose after 1-2 weeks according to symptoms.[1][14]​ Ibuprofen is frequently used because of its favorable side-effect profile compared with other drugs in this class; however, choice of drug should be based on patient characteristics (e.g., contraindications, previous efficacy, or adverse effects) and physician expertise.[1][18]​ Aspirin is preferred if required for persistent symptoms due to early pericarditis or late pericarditis post-myocardial infarction (MI) as other NSAIDs adversely affect myocardial healing, and for its antiplatelet activity. Glucocorticoids and NSAIDs (other than aspirin) are not indicated for post-MI pericarditis due to the potential for harm.[58]​ If NSAIDs or high-dose aspirin are not effective or are contraindicated, acetaminophen or an opioid may be considered.

Colchicine is recommended as a first-line adjunct therapy to NSAIDs as it improves response, decreases recurrences, and increases remission rates.[1][59] It is given for 3 months in this setting.[1][20][57][60] The addition of colchicine should be considered in patients with postcardiotomy injury syndromes (e.g., Dressler syndrome, which generally occurs 1-2 weeks after an MI; or postcardiac surgery), provided there are no contraindications and it is well tolerated. Preventive administration is recommended for 1 month. Careful follow-up with echocardiography every 6 to 12 months according to clinical features and symptoms should be considered to exclude possible evolution towards constrictive pericarditis.[1]

In cases of idiopathic or postviral pericarditis, if chest pain has not resolved after 2 weeks, a corticosteroid can be considered as an option in patients who do not respond to anti-inflammatory therapy, or for patients in whom an NSAID is contraindicated, once an infectious cause has been excluded. Corticosteroids are not recommended in patients with viral pericarditis because of the risk of re-activation of the viral infection and ongoing inflammation. Corticosteroids may also be used when there is a specific indication for their use (e.g., the presence of an autoimmune disease). They are used in combination with colchicine for this indication. Corticosteroids are less favored compared with NSAIDs because of the risks of promoting chronic and/or recurrent disease, and side effects.[1] If used, low to moderate doses are preferred over high doses.[18] The initial dose should be maintained until symptoms have resolved and the C-reactive protein (CRP) level has normalized. Once this is achieved, the dose may be gradually tapered.[1]

In addition to the above treatment, the underlying cause should also be treated if known. Underlying causes include viral infections (e.g., Coxsackie virus A9, B1-4, Echo 8, mumps, Epstein-Barr virus, cytomegalovirus, varicella, rubella, HIV, Parvo-19, SARS-CoV-2), tuberculosis (a common cause in the developing world), secondary immune processes (e.g., rheumatic fever, postcardiotomy syndrome, post-MI syndrome), metabolic disorders (e.g., uremia, myxedema), radiation therapy, 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, and neoplasms.

In patients with tuberculous pericarditis, first-line treatment is 4 to 6 weeks of antituberculous therapy.[1][3][16][37][61] When tuberculous pericarditis is confirmed in an nonendemic area, a suitable 6-month regimen is effective; empiric therapy is not required in the absence of an established diagnosis in nonendemic areas.[1] Adjunctive therapies such as colchicine, corticosteroids, and immunotherapy have not been shown to be beneficial.[62][63][64][65] However, corticosteroids may be considered in patients with tuberculous pericarditis who are HIV-negative.[66] [ Cochrane Clinical Answers logo ] ​​​ Pericardiectomy is recommended if the patient does not improve or is deteriorating after 4 to 8 weeks of antituberculosis therapy.[1][67] Most patients with uremic pericarditis respond to intensive dialysis within 1 to 2 weeks. Autoimmune disorders are treated with corticosteroids and/or other immunosuppressive therapies depending on the specific condition. Treatment of neoplasms may involve any combination of radiation therapy, chemotherapy, or surgery, depending on the type of tumor identified.[37][38] Patients with viral pericarditis may benefit from specific antiviral therapy; however, an infectious disease attending should be involved.

Exercise should be restricted until chest pain resolves and inflammatory markers have normalized.[55]​ A minimum of 3 months is often considered appropriate (and is recommended for those participating in competitive sports), but shorter periods of exercise restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

Nonpurulent disease: recurrent

For recurrent pericarditis, patients are treated with an NSAID plus colchicine, as well as exercise restriction. The NSAID should be continued until symptoms resolve, and the colchicine continued for 6 months to prevent recurrence. A longer duration of therapy for colchicine can be considered in resistant cases. CRP levels should be used to guide therapy and response. Once the CRP has normalized, drug therapy can be tapered gradually according to symptoms and the CRP level.[1]

For patients who do not respond to an NSAID plus colchicine, corticosteroid therapy can be considered as for patients at the initial presentation. Third-line therapies in recurrent disease are immunosuppressants, including intravenous immunoglobulin (IVIG), interleukin-1 inhibitors (anakinra, and rilonacept), and azathioprine.[68] All are off-label for pericarditis, except for rilonacept which is approved for recurrent pericarditis (but not first presentations).[18][42] These therapies should be used in consultation with a rheumatologist.[1][20][57][69][70][71][72] Further studies are needed.

For patients with persistent, symptomatic recurrence refractory to all medical treatment, pericardiotomy is recommended.[1] In tuberculous pericarditis, patients in whom there are recurrent effusions or evidence of constrictive physiology despite medical therapy, are treated surgically with pericardiectomy.[3] It 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 is recommended for the prevention of tuberculous pericardial constriction.[1][Figure caption and citation for the preceding image starts]: Pericardectomy 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].Pericardectomy in a 56-year-old male patient with idiopathic calcific constrictive pericarditis. The pericardium is thickened and calcified

Pericardiectomy may also be necessary for treatment of recurrent nontuberculous pericarditis refractory to standard therapies, where constriction is present (e.g., following cardiac surgery or radiation therapy, or idiopathic constrictive pericarditis).[42][73]

Exercise should be restricted until chest pain resolves and inflammatory markers have normalized.[55]​ A minimum of 3 months is often considered appropriate (and recommended for patients involved in competitive sports), but shorter periods of exercise restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

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