Pericarditis¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Apply diagnostic criteria for acute pericarditis (≥2 of 4: chest pain, rub, ECG changes, effusion)
[ ] Differentiate uncomplicated pericarditis from high-risk features requiring hospitalization
[ ] Evaluate for cardiac tamponade using clinical and echocardiographic criteria

Pharmacotherapy¶

[ ] Select appropriate first-line therapy (NSAID + colchicine) with correct dosing and duration
[ ] Justify why corticosteroids should be avoided as initial therapy (increase recurrence risk)
[ ] Formulate management plan for recurrent or refractory pericarditis (anakinra, rilonacept)

Communication & Counseling¶

[ ] Counsel patients on expected symptom duration, medication adherence, and activity restrictions
[ ] Discuss prognosis and recurrence risk (reduced 50% with colchicine)

Procedural & Systems¶

[ ] Recognize when pericardiocentesis is indicated and coordinate urgent intervention
[ ] Ensure appropriate activity restriction (no competitive sports) until symptoms and inflammation resolved

Key Guidelines¶

2015 ESC Guidelines for Pericardial Diseases (Core Document) European Heart Journal. 2015;36:2921-2964

2025 ESC Guidelines on Inflammatory Myocardial and Pericardial Syndromes

2025 ACC Expert Consensus Statement on Pericarditis

Quick Reference: Pericarditis Treatment Algorithm

Diagnostic Criteria¶

≥2 of 4 required: 1. Characteristic chest pain (pleuritic, positional, sharp) 2. Pericardial friction rub 3. ECG changes (diffuse ST elevation, PR depression) 4. New or worsening pericardial effusion

Classification¶

Type	Duration
Acute	New onset
Incessant	>4-6 weeks without remission
Recurrent	Recurrence after symptom-free interval ≥4-6 weeks
Chronic	>3 months

Poor Prognostic Predictors¶

Fever >38°C
Subacute onset
Large pericardial effusion
Tamponade
Failure to respond to NSAIDs within 1 week

First-Line Treatment (ALL Patients)¶

Agent	Pediatric Dose	Duration
NSAID	Ibuprofen 30-50 mg/kg/day divided TID (max 2400 mg/day)	1-2 weeks, then taper
Colchicine	<5 years: 0.5 mg daily; ≥5 years: 0.5-1 mg daily	3 months (first); 6 months (recurrence)
Gastroprotection	PPI or H2 blocker	Duration of NSAID

Pediatric-Specific Notes¶

AVOID ASPIRIN in children <12 years (Reye syndrome risk) - Class III

Colchicine is Class IIa in children
Indomethacin is alternative NSAID if ibuprofen ineffective

AVOID Corticosteroids Initially¶

Steroids increase recurrence risk

Reserve for:
NSAID contraindication
Renal insufficiency
Autoimmune/systemic inflammatory disease

If steroids needed: - Low dose: Prednisone 0.2-0.5 mg/kg/day - SLOW taper (months, not weeks) - Continue colchicine throughout

Second-Line Therapy (Refractory/Recurrent)¶

Low-dose corticosteroids (if not already tried)
Slow steroid taper over months
Continue colchicine throughout

Third-Line Therapy (Colchicine-resistant, Steroid-dependent)¶

IL-1 Inhibitors: - Anakinra (AIRTRIP trial) - daily injection - Rilonacept (RHAPSODY trial) - weekly injection

Pre-treatment screening: - TB - Hepatitis B/C - HIV

Exercise Restriction¶

MANDATORY: - Until clinical remission - Until CRP normalized - Minimum 1 month - Longer for athletes (until completely resolved) - Avoid HR >100 bpm during recovery

Recurrence Prevention¶

Colchicine reduces recurrence by ~50%
Longer colchicine course for recurrent cases (6 months)
Slow NSAID taper (don't stop abruptly)

Recurrence Rates¶

| Without colchicine | 15-30% | | With colchicine | ~10-15% |

Board Pearls¶

Pearl: NSAID + colchicine is first-line (NOT steroids)

Steroids increase recurrence risk

Pearl: Avoid aspirin in children <12 years (Reye syndrome)

Use ibuprofen or indomethacin instead

Pearl: Colchicine reduces recurrence by 50%

IL-1 inhibitors (anakinra, rilonacept) for refractory cases

Self-Assessment¶

Q1: A 10-year-old presents with sharp chest pain worse with inspiration and lying flat, pericardial friction rub, and diffuse ST elevations. What is the first-line treatment?

Answer

**Answer**: Ibuprofen + colchicine (+ PPI for gastroprotection) **Rationale**: This patient meets diagnostic criteria for acute pericarditis (characteristic pain + friction rub + ECG changes). First-line treatment is NSAID + colchicine. Aspirin is avoided in children <12 years due to Reye syndrome risk. Steroids should NOT be used first-line as they increase recurrence.

Q2: A 14-year-old with recurrent pericarditis has failed two courses of NSAIDs + colchicine and is now dependent on prednisone (flares when tapered below 10 mg). What is the next therapeutic option?