Bedside Rounds

Acute pericarditis: workup and management

Acute pericarditis needs 2 of 4: pericarditic chest pain, friction rub, widespread ST elevation or PR depression, new or worsening effusion. Exclude MI, tamponade and myocarditis, look for high-risk features, and treat with an NSAID or aspirin plus colchicine.

Working diagnosis Adult · US guidelines Draft · awaiting physician review
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01Orient

What's new in the evidence

  • 2025 ACC expert consensus on pericarditis: NSAID or aspirin plus colchicine first line; colchicine for 3 months after a first episode and at least 6 months after recurrence
  • Anti-IL-1 therapy (anakinra, rilonacept) preferred over corticosteroids for recurrent pericarditis with an inflammatory phenotype
  • Restrict strenuous exercise for at least 1 month (3 months for athletes, longer with myocarditis)

Differential diagnoses

  1. STEMI (can't miss)
  2. Cardiac tamponade (can't miss)
  3. Myopericarditis (troponin elevation)
  4. Aortic dissection with hemopericardium (can't miss)
  5. Pneumonia, pleuritis, PE
  6. Causes: viral/idiopathic, post-MI or post-cardiac injury, uremic, malignancy, autoimmune, TB, drugs (checkpoint inhibitors)

02Assess

Risk scores and decision tools

  • ESC/ACC diagnostic criteria (2 of 4)
  • High-risk features: fever >38 °C, subacute onset, large effusion or tamponade, failure of NSAIDs, immunosuppression, trauma, oral anticoagulation, myopericarditis
  • Echocardiographic tamponade signs

Key history questions

  • Sharp chest pain, better sitting forward, worse lying flat or breathing
  • Recent viral illness, fever
  • Recent MI, cardiac surgery or procedure
  • Kidney disease, cancer, autoimmune disease, TB exposure
  • Anticoagulant use; checkpoint inhibitors

Examination findings

  • Friction rub (best heard leaning forward at end-expiration)
  • Pulsus paradoxus, raised JVP, hypotension (tamponade)
  • Fever
  • Signs of systemic disease

03Investigate

Initial investigations

  • ECG: diffuse concave ST elevation with PR depression; serial ECGs
  • Troponin (myopericarditis), CRP, CBC, BMP
  • Chest X-ray
  • Transthoracic echocardiogram

Advanced investigations

  • Cardiac MRI for myopericarditis or recurrent disease
  • ANA, TB testing, TSH, blood cultures if high-risk features
  • Pericardiocentesis for tamponade or suspected bacterial, TB or malignant effusion

04Treat

Immediate management

  • Tamponade: urgent pericardiocentesis; avoid diuretics and vasodilators
  • Exclude STEMI before treating as pericarditis

First-line treatment

  • Ibuprofen 600–800 mg every 8 hours (or aspirin 750–1000 mg every 8 hours after MI) for 1–2 weeks, then taper as CRP normalizes
  • Colchicine 0.6 mg twice daily (once daily if <70 kg or older) for 3 months
  • PPI while on NSAIDs
  • Exercise restriction for at least 1 month

Second-line treatment

  • Low-dose prednisone 0.2–0.5 mg/kg/day if NSAIDs contraindicated, with slow taper (raises recurrence)
  • Recurrent pericarditis with inflammatory phenotype: anakinra or rilonacept
  • Treat specific causes (dialysis for uremic, antituberculous therapy, etc.)

Specialist referrals

  • Cardiology for high-risk features or recurrence
  • Cardiothoracic surgery for constrictive pericarditis

05Disposition

Admission criteria

  • Any high-risk feature (fever, large effusion, tamponade, myopericarditis, anticoagulation, immunosuppression, NSAID failure)

Safe discharge criteria

  • No high-risk features, pain controlled, small or no effusion
  • Follow-up in 1 week with CRP

Follow-up timing

  • Review in 1–2 weeks; CRP to guide taper

Patient instructions

  • Avoid strenuous exercise until symptoms and CRP resolve
  • Return for breathlessness, fainting or worsening pain

Monitoring

  • CRP every 1–2 weeks
  • Echo if symptoms change

Clinical pearls and pitfalls

  • Colchicine halves recurrence (ICAP)
  • Corticosteroids as first line increase recurrence; avoid unless specific indication
  • Avoid NSAIDs other than aspirin early after MI

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.

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