• True incidence of pericarditis unknown: 5% of non-ACS “chest pain” ED visits.
• Cardiac tamponade can occur in up to 15% of cases.
• Important to distinguish from ACS.
• Inflammatory condition of the pericardium:
  • Infectious etiologies
    • Most common cause is viral or idiopathic as etiologic agent is rarely identified.
    • Consider tuberculosis if recent travel to an endemic region.
  • Non-infectious etiologies
    • Autoimmune conditions – SLE, RA, scleroderma, sarcoid, vasculitis.
    • Autoinflammatory pericardial syndromes (Dressler syndrome): post myocardial infarction, cardiac surgery or cardiac trauma.
    • Neoplastic: (metastatic: lung>breast>leukaemia and lymphoma>melanoma).
    • Radiation.
    • Metabolic (uremia).
    • Drug-related.
  • Symptoms usually last 4-6 weeks but other forms exist
    • Incessant pericarditis: up to 3 months.
    • Recurrent/relapsing pericarditis: symptoms recur after a symptom-free period.
    • Chronic pericarditis: symptoms > 3 months.

• Outpatient management is recommended for low-risk patients who have no criteria for hospital admission.
• Consider admission/same-day consult:
  • For diagnosis or etiologic ambiguity: Underlying etiology unlikely to be viral/idiopathic.
  • Myocarditis or myopericarditis (significant troponin elevation).
  • Significant abnormal vital signs or tachycardia out of proportion to pain/fever.
  • Large pericardial effusion (> 20 mm on echo).
  • Relapsing/recurrent, incessant or chronic pericarditis.
  • Figure 2 below outlines triage scheme of pericarditis.

Created By Ella Barrett-Chan, MSI UBC

• Restrict physical activity (minimal activity) until resolution of symptoms and normalization of CRP.
• Treat underlying condition (ex. Antibiotics for purulent pericarditis).
• First line treatment
  • NSAIDs OR Aspirin + Colchicine.
  • Recommend GI protection with PPI.
• Second line treatment
  • Prednisone + Colchicine.
    • In retrospective studies steroids associated with higher recurrence rate.
    • Only use steroids if contraindications to NSAIDs/Aspirin or specific indication (ex. systemic inflammatory disease).

• NSAIDs
  • Ibuprofen 600-800 mg po q8h.
    • 7-14 days, then taper by 200-400 mg every 1-2 weeks.
  • Aspirin 750 to 1000 mg po TID in patients with concomitant CAD.
    • 7-14 days, then taper by 250-500 mg every 1-2 weeks.

• Colchicine
  • Patients > 70 kg: 0.5 mg PO BID.
  • Patients < 70 kg: 0.5 mg PO daily.
  • Duration: 3 months.
    • Tapering not required.

• Prednisone
  • 0.2-0.5 mg/kg/day PO.
  • Slow taper recommended (see table in Figure 1).
  • Requires exclusion of infectious (bacteria / TB) etiology.

Figure 2: Recommended tapering schedule of prednisone based on starting dose.
Source: Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318

• If there is high clinical suspicion for cardiac tamponade, drainage of the pericardial fluid is required urgently.
  • Needle pericardiocentesis with FAST US, echocardiographic or fluoroscopic guidance.
  • Surgical drainage.
• See emergent pericardiocentesis video: Emergency Pericardiocentesis.

• Site/region specific.
• Consider hemodynamic stability and length of travel prior to transport.

• Follow up with primary care provider (unless consultant involved) within 7 days to ensure adequate response to treatment and monitoring of CRP.

• Prognosis for acute viral/idiopathic pericarditis is quite good with treatment.
  • Cardiac tamponade rarely occurs.
  • Constrictive pericarditis develops in less than 1%.

1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318

   
   

2. Doctor NS, Shah AB, Coplan N, Kronzon I. Acute Pericarditis. Prog Cardiovasc Dis. 2017;59(4):349-359. doi:10.1016/j.pcad.2016.12.001

   
   

3. Imazio M, Gaita F. Diagnosis and treatment of pericarditis. Heart. 2015;101(14):1159-1168. doi:10.1136/heartjnl-2014-306362

   
   

4. Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(1):76-92. doi:10.1016/j.jacc.2019.11.021

   
   

5. Fitch MT, Nicks BA, Pariyadath M, McGinnis HD M DE. Videos in clinical medicine. Emergency pericardiocentesis. N Engl J Med. 2102;366(12).

   
   

6. Raval J, Nagaraja V, Eslick GD, Denniss AR. The role of colchicine in pericarditis – a systematic review and meta-analysis of randomised trials. Hear Lung Circ. 2015;24(7):660-666. doi:10.1016/j.hlc.2015.01.010

   
   

7. Imazio M, Cecchi E, Demichelis B, et al. Indicators of poor prognosis of acute pericarditis. Circulation. 2007;115(21):2739-2744. doi:10.1161/CIRCULATIONAHA.106.662114