Guideline 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 of Cardiology (ESC/ESTRO/EHA/IC-OS 2022), the European Society for Microbiology and Infectious Diseases (ESCMID 2022), the Society of Cardiovascular Computed Tomography (SCCT/SCMR/AHA/SAEM/ASE/ACC/ACCP 2021), the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the Single Hub and Access Point for Pediatric Rheumatology in Europe (SHARE initiative 2019), the American Heart Association (AHA/ASA 2018), the Pan-American League of Associations of Rheumatology (PANLAR 2018), the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ERN ReCONNET 2018), the Brazilian Society of Cardiology (BSC/ASE 2018), the European Society of Cardiology (ESC/EACTS 2015), the Wilderness Medical Society (WMS 2014), and the American Heart Association (AHA/ACC 2013). 1 2 3 4 6 7 9 10 11 12 13 14 15 16 16 17 17 Definition Acute pericarditis is a disease characterized by acute inflammation of the pericardium. 15 E id i l https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 1/8 6/23/23, 2:02 AM Acute pericarditis Pathway Epidemiology 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. 17 Pathophysiology In the United States, the incidence of acute pericarditis requiring hospitalization is estimated at 26 cases per 100,000 person-years. 16 Disease course Inflammation of the pericardium results in the formation of a pericardial effusion, which may progress to cardiac tamponade and obstructive shock. 17 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. 16 Calculator Calculator Calculator Diagnostic criteria for acute peri NYHA functional classification f Risk strati Guidelines 1. Screening and diagnosis Diagnostic criteria: 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). 2. Diagnostic investigations Initial evaluation: assess for independent predictors of an identifiable and specifically treatable cause of pericarditis (such as bacterial, neoplastic, or systemic inflammatory diseases). B Show 3 more Transthoracic echocardiography: Obtain TTE in patients with acute chest pain with suspected pericardial effusion. Consider obtaining TTE to determine the presence of pericardial effusion or restrictive physiology in patients with acute chest pain and suspected myopericarditis. (COR : 1, LOE : C-EO). B https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 2/8 6/23/23, 2:02 AM Acute pericarditis Pathway Obtain TTE to assess for pericardial effusion in intermediate-risk patients with acute chest pain. B Consider obtaining TTE to detect pericardial abnormalities in intermediate-high-risk patients with stable chest pain having Q waves, symptoms or signs suggestive of HF, or a heart murmur with an unclear diagnosis. B Cardiac MRI/CT: As per AHA 2021 guidelines, consider obtaining cardiac MRI with gadolinium contrast to distinguish myopericarditis from other causes, including myocardial infarction and nonobstructive coronary arteries, in patients with acute chest pain and myocardial injury having nonobstructive coronary arteries on anatomic testing. B Show 2 more As per ESC 2015 guidelines, obtain cardiac MRI for the confirmation of myocardial involvement in patients with suspected myopericarditis. B Show 2 more Evaluation for viral pericarditis: Do not obtain routine viral serologies, with the possible exception of human immunodeficiency virus and HCV testing. D Consider obtaining a comprehensive panel of histological, cytological, immunohistological, and molecular investigations in pericardial fluid and peri-/epicardial biopsies, for the definite diagnosis of viral pericarditis. C 3. Diagnostic procedures Coronary angiography: 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 Diagnostic pericardiocentesis: consider performing diagnostic pericardiocentesis in all patients with suspected tuberculous pericarditis. C Show 2 more Pericardial biopsy: consider performing percutaneous or surgical pericardial biopsy in selected patients with suspected or tuberculous pericarditis. C 4. Medical management Setting of care: 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 Nonsteroidal anti-inflammatory drugs: Administer aspirin or NSAIDs as first-line therapy for acute pericarditis, in conjunction with prophylactic acid-suppressive therapy. A https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 3/8 6/23/23, 2:02 AM Acute pericarditis Pathway Consider administering empirical anti-inflammatory therapies (lowest efficacious doses) to control chest pain. C Colchicine: administer colchicine (0.5 mg 1-2 times daily in patients < 70 kg or intolerant to higher doses) as first-line therapy for acute pericarditis as an adjunct to aspirin/NSAID therapy. A Landmark trials: ICAP In adults with acute pericarditis who were receiving conventional treatment, colchicine was superior to placebo with respect to incessant or recurrent pericarditis. Imazio M et al. N Engl J Med. 2013 Oct 17. Corticosteroids: Consider administering low-dose corticosteroids in patients with acute pericarditis in case of aspirin/NSAID and colchicine failure/contraindication or where there is a specific indication for corticosteroids (such as corticosteroid-responsive autoimmune diseases), if infectious causes have been excluded. C Do not use corticosteroids in patients with viral pericarditis. D Management of recurrent pericarditis: administer aspirin and NSAIDs (at full doses, if tolerated) for the treatment of recurrent pericarditis, continued until complete symptom resolution. A Show 5 more 5. Nonpharmacologic interventions Exercise restriction (simple pericarditis): 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 Exercise restriction (myopericarditis): advise rest and avoidance of physical activity beyond normal sedentary activities for 6 months in non-athletes and athletes with myopericarditis. B 6. Specific circumstances Pediatric patients: administer NSAIDs at high doses as first-line therapy for acute pericarditis in pediatric patients until complete symptom resolution. B Show 4 more Patients with purulent pericarditis: perform effective pericardial drainage in patients with purulent pericarditis. B Show 3 more https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 4/8 6/23/23, 2:02 AM Acute pericarditis Pathway Patients with uremic pericarditis: consider performing dialysis for the treatment of uremic pericarditis. C Show 4 more Patients with post-cardiac injury syndromes: As per ESC 2015 guidelines, consider administering colchicine after cardiac surgery using weight-adjusted doses (0.5 mg once in patients 70 kg; 0.5 mg BID in patients > 70 kg) and without a loading dose for the prevention of postpericardiotomy syndrome, if there are no contraindications and it is tolerated. Continue preventive administration of colchicine for 1 month. B Show 4 more As per AHA 2013 guidelines, administer aspirin in patients with pericarditis following STEMI. B Show 2 more Patients with radiation pericarditis: As per ESC 2022 guidelines, consider obtaining echocardiography surveillance every 5 years in patients after acute pericarditis developed during radiotherapy to a volume including the heart, as these patients are at higher risk of developing chronic constrictive pericarditis. C As per ESC 2015 guidelines, use radiation therapy methods reducing both the volume and the dose of cardiac irradiation, whenever possible, to reduce the risk of radiation pericarditis. B Patients chemotherapy-induced pericarditis: diagnose and manage acute pericarditis in patients with cancer according to current published guidelines for the diagnosis and management of pericardial diseases. Arrange a multidisciplinary discussion before interrupting cancer therapy. B Show 3 more Patients with neoplastic pericardial disease: obtain cytological analyses of pericardial fluid to confirm the malignant pericardial disease. B Show 5 more Patients with systemic lupus erythematosus: consider administering colchicine plus standard of care (hydroxychloroquine and corticosteroids) in patients with acute SLE-related pericarditis. C Patients with relapsing polychondritis: administer corticosteroids, conventional synthetic DMARDs, conventional immunosuppressive agents (such as methotrexate), or biologics in patients with relapsing polychondritis with pericardial involvement. E Patients with polyarteritis nodosa: consider obtaining an ECG and echocardiography for the identification of pericarditis, valve insufficiency, myocarditis, or coronary artery abnormalities in patients with polyarteritis nodosa. C Patients with Lyme disease: Test for Lyme disease in patients with acute myocarditis/pericarditis of unknown cause in an appropriate epidemiologic setting. B Hospitalize and obtain continuous ECG monitoring in patients with or at risk for severe cardiac complications of Lyme disease, including patients with clinical manifestations of myopericarditis. https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 5/8 6/23/23, 2:02 AM Acute pericarditis Pathway B Patients with Chagas disease: suspect acute Chagas disease in patients with a febrile illness accompanied by myocarditis findings on echocardiography and/or pericardial fluid in endemic countries and in Latin American immigrants with immunosuppressed states living in nonendemic countries. Obtain echocardiography in patients with suspected acute Chagas disease. Recognize that hypotension may be a sign of hemodynamically significant pericardial effusion leading to cardiac tamponade. E Patients with lightning injury: counsel patients with lightning injury at discharge to return if they exhibit new chest pain or dyspnea because delayed or recurring cardiac injuries such as pericarditis or cardiomyopathy are possible. B Patients with long COVID: Consider obtaining a TTE in patients presenting with persistent symptoms suggestive of perimyocardial injury (chest pain, palpitations, signs and symptoms of HF) after COVID-19 inection. Consider repeating TTE at 2-3 months in patients with cardiac abnormalities during acute disease (myocarditis, pericarditis, HF). E Exclude other serious/life-threatening conditions including prior overlooked conditions (such as malignancy) and complications of acute COVID-19 (such as thromboembolic events, myopericarditis, and encephalitis) before diagnosing long COVID in symptomatic patients. Evaluate for other conditions guided by symptoms, signs, and other tests, obtained according to the physician's discretion. E Patients with acute ischemic stroke: Consider administering IV alteplase in patients with acute pericarditis and major acute ischemic stroke likely to produce severe disability. C Insufficient evidence to recommend administering IV alteplase in patients presenting with acute pericarditis and moderate acute ischemic stroke likely to produce mild disability. I 7. Follow-up and surveillance Follow-up: 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 towards constrictive pericarditis. C Likelihood Ratios Pertinent positives The following findings increase the probability of acute pericarditis in adults. -1 Finding LR+ Value https://web.pathway.md/diseases/recyJEDIlWYQGdBVy 6/8 6/23/23, 2:02 AM Acute pericarditis Pathway 78 Increased serum D-dimer Presence of PR depression or diffuse ST elevation 39 History of pleuritic chest pain relieved by sitting up 24 Presence of pericardial friction rub 9.0 Show 2 more Pertinent negatives The following findings decrease the probability of acute pericarditis in adults. -1 Finding LR- Value serum D-dimer not increased 0.22 No history of pleuritic chest pain 0.43 Absence of pericardial thickening 0.47 Absence of PR depression or diffuse ST elevation 0.62 Show 2 more References 1. 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