Pericarditis Treatment Algorithm

flowchart TD
    A[Acute Pericarditis<br/>≥2 of 4 criteria] --> B{Troponin elevated?}

    B -->|Yes| C[Myopericarditis<br/>Longer restriction]
    B -->|No| D[Isolated Pericarditis]

    C --> E[First-Line Therapy]
    D --> E

    E --> E1[NSAID + Colchicine]
    E1 --> E2[Ibuprofen 600mg TID<br/>or Naproxen 500mg BID]
    E1 --> E3[Colchicine 0.5mg BID<br/>x 3 months]

    E2 & E3 --> F{Response in 1-2 weeks?}

    F -->|Yes - Improving| G[Continue treatment<br/>Taper NSAIDs when CRP normal]
    F -->|No - Refractory| H[Increase NSAID dose<br/>Ensure colchicine adherence]

    H --> I{Still refractory?}
    I -->|Yes| J{NSAID contraindicated?}

    J -->|Yes| K[Low-dose Corticosteroids<br/>Prednisone 0.25-0.5 mg/kg]
    J -->|No| L[Triple Therapy:<br/>NSAID + Colchicine + Low-dose steroid]

    K --> M[VERY slow taper<br/>over months]
    L --> M

    M --> N{Recurrence?}
    N -->|Yes - First recurrence| O[Repeat NSAID + Colchicine<br/>Extend colchicine to 6 months]
    N -->|Yes - Multiple recurrences| P[Consider:<br/>• Anakinra<br/>• Azathioprine<br/>• Pericardiectomy]
    N -->|No| Q[Continue surveillance]

    G --> R[Activity Restriction]
    R --> R1[Pericarditis: 2-4 weeks]
    R --> R2[Myopericarditis: 3-6 months]

    R1 & R2 --> S[Return to Activity Criteria]
    S --> S1[Asymptomatic]
    S --> S2[CRP normalized]
    S --> S3[Echo normalized]
    S --> S4[If myopericarditis: CMR clear]

    style K fill:#ffd93d
    style P fill:#ff6b6b

📋 Text Version (if diagram doesn't render)

**Pericarditis Treatment Algorithm** 1. **Troponin elevated?** → Myopericarditis (longer restriction) vs Isolated pericarditis 2. **First-Line:** NSAID (Ibuprofen 600mg TID or Naproxen 500mg BID) + Colchicine 0.5mg BID x 3 months 3. **Response in 1-2 weeks?** - YES → Continue, taper NSAIDs when CRP normal - NO → Increase NSAID, ensure colchicine adherence 4. **Still refractory?** → Low-dose steroids (0.25-0.5 mg/kg) if NSAID contraindicated; VERY slow taper 5. **Recurrence?** - First → Repeat NSAID + colchicine (6 months) - Multiple → Anakinra, Azathioprine, or Pericardiectomy 6. **Activity Restriction:** Pericarditis 2-4 weeks; Myopericarditis 3-6 months

Diagnostic Criteria (≥2 of 4)

1. Pleuritic chest pain (sharp, worse supine, better sitting forward)
2. Pericardial friction rub (scratchy, 3-component)
3. ECG changes (diffuse ST elevation, PR depression)
4. Pericardial effusion (new or worsening)

First-Line Treatment

NSAIDs

Drug	Dose	Duration
Ibuprofen	600mg TID	Until symptoms resolve + CRP normal
Naproxen	500mg BID	Then taper over 2-4 weeks
Indomethacin	50mg TID	Alternative

Add GI protection (PPI) if risk factors

Colchicine (KEY for preventing recurrence)

Weight	Dose	Duration
<70 kg	0.5mg daily	3 months
≥70 kg	0.5mg BID	3 months

Side effects: GI (diarrhea), reduce dose if needed

Corticosteroids

When to Use

• NSAID contraindication (renal failure, GI bleeding)
• NSAID failure despite adequate trial
• Autoimmune/inflammatory etiology
• Pregnancy

Dosing

• LOW dose: 0.25-0.5 mg/kg/day prednisone
• SLOW taper: Decrease by 2.5-5mg every 2-4 weeks
• Total taper duration: 2-3+ months

WARNING: Steroids INCREASE recurrence risk - avoid if possible

Recurrent Pericarditis

Definition

Recurrence after symptom-free interval ≥4-6 weeks

Management

1. First recurrence: Repeat NSAID + colchicine (extend to 6 months)
2. Second recurrence: Add low-dose steroid if not already
3. Multiple recurrences:
4. Anakinra (IL-1 blocker) - AIRTRIP trial
5. Azathioprine
6. IVIG
7. Pericardiectomy (last resort)

Activity Restriction

Condition	Minimum Restriction
Uncomplicated pericarditis	2-4 weeks
Myopericarditis	3-6 months
Athletes	Until asymptomatic + normal CRP + normal echo

Red Flags (Consider Other Etiologies)

• Fever >38°C beyond first week
• Large effusion or tamponade
• Failure to respond to NSAIDs
• Immunocompromised host
• Trauma/post-procedural
• Signs of systemic disease