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Acute pericarditis

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Updated 2022 ESC/EHA and 2021 AHA/ACC for the diagnosis and management of acute pericarditis.

Background

Overview

Definition
Acute pericarditis is a disease characterized by acute inflammation of the pericardium.
1
Pathophysiology
Most cases of acute pericarditis are idiopathic (80-90%) and assumed to be due to viral infection. Other important causes include post-cardiac injury syndromes, connective tissue diseases (such as SLE), and cancer.
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Epidemiology
In the US, the incidence of acute pericarditis requiring hospitalization is estimated at 26 cases per 100,000 person-years.
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Disease course
Inflammation of the pericardium results in the formation of a pericardial effusion, which may progress to cardiac tamponade and obstructive shock.
2
Prognosis and risk of recurrence
Acute pericarditis is associated with 5.7% all-cause mortality at 30 days, and 17.3% all-cause mortality at 1 year.
3

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute pericarditis are prepared by our editorial team based on guidelines from the European Society for Microbiology and Infectious Diseases (ESCMID 2022), the European Society of Cardiology (ESC/ESTRO/EHA/IC-OS 2022), the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the Society of Cardiovascular Computed Tomography (SCCT/SCMR/AHA/SAEM/ASE/ACC/ACCP 2021), the Single Hub and Access...
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Screening and diagnosis

Diagnostic criteria: as per EACTS/ESC 2015 guidelines, Make a clinical diagnosis of acute pericarditis in patients with ≥ 2 out of 4 suggestive clinical criteria (chest pain, pericardial rub, ECG changes, and pericardial effusion).
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Diagnostic investigations

Initial evaluation: as per EACTS/ESC 2015 guidelines, Assess for independent predictors of an identifiable and specifically treatable cause of pericarditis (such as bacterial, neoplastic, or systemic inflammatory diseases).
B
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  • Transthoracic echocardiography

  • Cardiac MRI/CT

  • Evaluation for viral pericarditis

Diagnostic procedures

Coronary angiography: as per EACTS/ESC 2015 guidelines, Perform coronary angiography (according to clinical presentation and risk factor assessment) to rule out acute coronary syndromes in patients with pericarditis and suspected myocarditis.
B
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  • Diagnostic pericardiocentesis

  • Pericardial biopsy

Medical management

Setting of care
As per EACTS/ESC 2015 guidelines:
Offer outpatient management in low-risk patients with acute pericarditis.
B
Admit high-risk patients with acute pericarditis to the hospital.
B
Admit patients with myocardial involvement to the hospital for diagnosis and monitoring.
B
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  • NSAIDs

  • Colchicine

  • Corticosteroids

  • Management of recurrent pericarditis

Nonpharmacologic interventions

Exercise restriction, simple pericarditis
As per EACTS/ESC 2015 guidelines:
Consider advising exercise restriction until resolution of symptoms and normalization of CRP, ECG, and echocardiogram in non-athletes with acute pericarditis.
C
Consider advising exercise restriction for at least 3 months and until resolution of symptoms and normalization of CRP, ECG, and echocardiogram in athletes with acute pericarditis.
C
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  • Exercise restriction (myopericarditis)

Specific circumstances

Pediatric patients: as per EACTS/ESC 2015 guidelines, Administer NSAIDs at high doses as first-line therapy for acute pericarditis in pediatric patients until complete symptom resolution.
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  • Patients with purulent pericarditis

  • Patients with uremic pericarditis

  • Patients with post-cardiac injury syndromes

  • Patients with radiation pericarditis

  • Patients chemotherapy-induced pericarditis

  • Patients with neoplastic pericardial disease

  • Patients with SLE

  • Patients with relapsing polychondritis

  • Patients with polyarteritis nodosa

  • Patients with Lyme disease

  • Patients with Chagas disease

  • Patients with lightning injury

  • Patients with long COVID

  • Patients with AIS

Follow-up and surveillance

Follow-up
As per EACTS/ESC 2015 guidelines:
Schedule follow-up 1 week after treatment initiation to assess response to anti-inflammatory therapy.
B
Consider obtaining echocardiography every 6-12 months after post-cardiac injury pericarditis to exclude possible evolution toward constrictive pericarditis.
C
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