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 – assess risk and consider admission to hospital

Back

1st line –

assess risk and consider admission to hospital

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] Patients with any of these risk factors warrant careful observation and follow-up.

Major risk factors include: 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 include: 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]

Consider – pericardiocentesis

ACUTE

purulent

1st line – pericardiocentesis + intravenous antibiotics

Back

1st line –

pericardiocentesis + intravenous antibiotics

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]

Urgent rinsing of the pericardial cavity and intravenous antibiotics are mandatory.[37][38]

Empiric intravenous antibiotic therapy is recommended until microbiologic results are available. There are limited data available to guide selection of the best empiric regimen, 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 for choice of antibiotics 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.

Plus – nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Back

Plus –

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Treatment recommended for ALL patients in selected patient group

An NSAID should be started immediately on diagnosis for symptom management.[16][20][37][57] Consider tapering the dose after 1-2 weeks according to symptoms.[1] NSAIDs reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.[37][38]

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 favored over other NSAIDs if antiplatelet therapy is required), and physician expertise.[1]

Alternatively, acetaminophen or an opioid (e.g., codeine) can be considered if NSAIDs are not effective or are contraindicated.

Primary options

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

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

Secondary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

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]

Consider – proton-pump inhibitor

Consider – colchicine

Back

Consider –

colchicine

Treatment recommended for SOME patients in selected patient group

Should be used with caution in patients with purulent pericarditis as it may interfere with leukocyte function and infection clearance.[54]

It is given for 3 months in the setting of acute pericarditis.[1][20][57][60]

While tapering the dose is not mandatory, it can be considered in the last few weeks of treatment to prevent persistence of symptoms and recurrence.[1]

Before commencing treatment, a baseline complete blood count (CBC) is indicated as colchicine may cause neutropenia and bone marrow suppression. Caution should be exercised in renal and hepatic impairment as its use may be contraindicated in patients on certain medications.

Primary options

colchicine: <70 kg body weight: 0.6 mg orally once daily; ≥70 kg body weight: 0.6 mg orally twice daily

2nd line – pericardiotomy/pericardiectomy

non-purulent

idiopathic

1st line – nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Back

1st line –

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Alternatively, acetaminophen or an opioid (e.g., codeine) can be considered if NSAIDs are not effective or are contraindicated.

Primary options

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

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

Secondary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

Plus – colchicine

Back

Plus –

colchicine

Treatment recommended for ALL patients in selected patient group

Improves response, decreases recurrence, and increases remission rates.[1][59] It is given for 3 months in this setting.[1][20][57][60]

While tapering the dose is not mandatory, it can be considered in the last few weeks of treatment to prevent persistence of symptoms and recurrence.[1]

Primary options

colchicine: <70 kg body weight: 0.6 mg orally once daily; ≥70 kg body weight: 0.6 mg orally twice daily

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

Consider – proton-pump inhibitor

2nd line – corticosteroid

Back

2nd line –

corticosteroid

A corticosteroid can be considered in patients who do not respond to anti-inflammatory therapy or 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 viral infection and ongoing inflammation. Corticosteroids may also be used when there is a specific indication for their use (e.g., presence of an autoimmune disease).[1]

They are used in combination with colchicine for this indication.[1]

Corticosteroids are less favored compared to 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]

Primary options

prednisone: 0.25 to 0.5 mg/kg/day orally, taper gradually after resolution of symptoms and normalization of CRP

Plus – colchicine

Back

Plus –

colchicine

Treatment recommended for ALL patients in selected patient group

Improves response, decreases recurrence, and increases remission rates.[1][59] It is given for 3 months in this setting.[1][20][57][60]

While tapering the dose is not mandatory, it can be considered in the last few weeks of treatment to prevent persistence of symptoms and recurrence.[1]

Primary options

colchicine: <70 kg body weight: 0.6 mg orally once daily; ≥70 kg body weight: 0.6 mg orally twice daily

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

not idiopathic

1st line – treatment of the underlying cause

Back

1st line –

treatment of the underlying cause

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-myocardial infaction [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. Patients with viral pericarditis may benefit from specific antiviral therapy; however, an infectious disease attending should be involved.

In patients with tuberculous pericarditis, first-line treatment is 4 to 6 weeks of antituberculous therapy.[1] When tuberculous pericarditis is confirmed in a 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] [ ] 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 another immunosuppressive therapy depending on the specific condition. Aspirin is preferred if required for persistent symptoms due to early pericarditis or late pericarditis post-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]

Treatment of neoplasms may involve any combination of radiation therapy, chemotherapy, or surgery depending on the type of tumor identified.[37][38]

Plus – nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Back

Plus –

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Treatment recommended for ALL patients in selected patient group

Aspirin is the preferred NSAID in patients developing pericarditis after a myocardial infaction.[37][38]

Alternatively, acetaminophen or an opioid (e.g., codeine) can be considered if NSAIDs are not effective or are contraindicated.

Primary options

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

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

Secondary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

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 restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

Consider – colchicine

Back

Consider –

colchicine

Treatment recommended for SOME patients in selected patient group

Improves response, decreases recurrence, and increases remission rates.[1][59] It is given for 3 months in this setting.[1][20][57][60] Not shown to be beneficial in patients with tuberculous pericarditis.[64][65]

Addition of colchicine should be considered in patients with postcardiotomy injury syndromes (e.g., Dressler syndrome, which generally occurs 1-2 weeks after a myocardial infaction [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]

While tapering the dose is not mandatory, it can be considered in the last few weeks of treatment to prevent persistence of symptoms and recurrence.

Primary options

colchicine: <70 kg body weight: 0.6 mg orally once daily; ≥70 kg body weight: 0.6 mg orally twice daily

Consider – proton-pump inhibitor

ONGOING

recurrent disease

1st line – nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Back

1st line –

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

An NSAID should be started immediately on diagnosis for symptom management. NSAIDs reduce fever, chest pain, and inflammation but do not prevent tamponade, constriction, or recurrent pericarditis.[37][38]

Alternatively, acetaminophen or an opioid (e.g., codeine) can be considered if NSAIDs are not effective or are contraindicated.

Treatment should be continued until symptoms resolve.

Primary options

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

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

Secondary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

Plus – colchicine

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

Plus – treatment of the underlying cause

Consider – proton-pump inhibitor

2nd line – corticosteroid

Back

2nd line –

corticosteroid

For patients who do not respond to an NSAID plus colchicine, corticosteroid therapy can be considered, once an infectious cause has been excluded. May also be used when there is a specific indication for their use (e.g., presence of an autoimmune disease). Should be used in combination with colchicine for this indication.[1]

Less favored compared to NSAIDs because of the risks of promoting chronic and/or recurrent disease, and side effects.[1]

Primary options

prednisone: 0.25 to 0.5 mg/kg/day orally, taper gradually after resolution of symptoms and normalization of CRP

Plus – colchicine

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

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 restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

3rd line – immunosuppressant

Back

3rd line –

immunosuppressant

Third-line therapies in recurrent disease are immunosuppressants, including intravenous immunoglobulin (IVIG), interleukin-1 inhibitors (e.g., anakinra, and rilonacept), and azathioprine. These therapies should be used in consultation with a rheumatologist.[1][20][57][68][69][70][71]

Primary options

azathioprine: consult specialist for guidance on dose

rilonacept: consult specialist for guidance on dose

anakinra: consult specialist for guidance on dose

immune globulin (human): consult specialist for guidance on dose

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

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 restriction may be considered depending on patient and disease characteristics (e.g., nonathletes and/or mild clinical picture).[1][14][37][56]

4th line – pericardiectomy

Back

4th line –

pericardiectomy

Patients with persistent symptomatic recurrence refractory to all medical treatment can be considered for surgical management with pericardiectomy.[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].

In patients with tuberculous pericarditis, pericardiectomy is reserved for those with recurrent effusions or evidence of constrictive physiology despite medical therapy.[2] It is particularly recommended if the patient’s condition is not improving or is deteriorating after 4 to 8 weeks of antituberculosis therapy.[1] 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]

Plus – exercise restriction

Back

Plus –

exercise restriction

Treatment recommended for ALL patients in selected patient group

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 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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Pericarditis

Treatment algorithm

suspected pericarditis

assess risk and consider admission to hospital

pericardiocentesis

purulent

pericardiocentesis + intravenous antibiotics

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Primary options

Secondary options

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

Primary options

Secondary options

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

Primary options

Secondary options

exercise restriction

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

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

pericardiotomy/pericardiectomy

non-purulent

idiopathic

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Primary options

Secondary options

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

Primary options

Secondary options

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

Primary options

Secondary options

colchicine

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

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

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

colchicine

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

not idiopathic

treatment of the underlying cause

nonsteroidal anti-inflammatory drug (NSAID) or alternative analgesia

Primary options

Secondary options

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

Primary options

Secondary options

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

Primary options

Secondary options

exercise restriction

colchicine