Treatment Guideline Chart

Pericarditis is the inflammation of the pericardial sac with or without pericardial effusion and accounts for approximately 5% of visits to the emergency room for chest pain without myocardial infarction.

The patient experiences chest pain that is central, sharp, pleuritic, worse with inspiration or lying down and improves with sitting up and leaning forward.

Acute pericarditis is characterized by new-onset pericarditis with at least 2 of the following:

  • Pericarditic chest pain
  • Pericardial friction rubs
  • New or worsening pericardial effusion
  • ECG finding of a new diffuse ST-segment elevation and/or PR depression

Acute%20pericarditis Management

Management of Other Forms of Acute Pericarditis

Acute Viral Pericarditis

  • Self-limiting disease treated with a short course of NSAID therapy and adjunctive Colchicine for recurrence prevention
  • Corticosteroids are not given as these may reactivate viral infections and result in ongoing inflammation

Bacterial Pericarditis

  • Tuberculous pericarditis is most common in developing countries
  • Empiric anti-TB chemotherapy is recommended for exudative pericardial effusion in endemic areas after excluding causes such as autoimmune diseases, malignancy, purulent pericarditis, uremia and trauma
  • HIV-negative cases of TB pericarditis may be given adjunctive steroids
  • If with cardiac tamponade, pericardiocentesis may be performed 

Constrictive Pericarditis

  • Can occur after any pericardial disease but rarely develops after recurrent pericarditis
    • Risk is low (1%) in patients with viral and idiopathic pericarditis, intermediate (2-5%) for neoplastic, autoimmune and immune-mediated etiologies, and high (20-30%) for bacterial causes, eg TB and purulent pericarditis
  • It is recommended to medically treat specific conditions (eg tuberculous pericarditis) to avoid progression of constriction and to control symptoms of congestion
  • Effusive-constrictive pericarditis may be treated with pericardiocentesis, chronic permanent constriction with pericardiectomy

Drug-related Acute Pericarditis and Pericardial Effusion

  • Damage to the pericardium is associated with “serum sickness” brought about by blood products, direct pericardial applications of talc or magnesium silicate, sclerosants, asbestos and iron in beta thalassemia
  • Anticoagulant therapies may cause hemorrhagic or worsening pericardial effusion that may lead to cardiac tamponade, though this is not supported by current available data
  • Management is stopping the causative agent and administering symptomatic treatment

Fungal Pericarditis

  • Rare form of pericarditis which may be caused by Histoplasma (in immunocompetent patients), Aspergillus or Candida sp (in immunocompromised patients)
  • May be treated with NSAIDs; consider antifungal therapy for disseminated histoplasmosis

Malignant Pericarditis

  • May be due to metastasis from a primary tumor [eg breast cancer, lymphoma, leukemia, melanoma (less common)]
  • Pericardiocentesis or drainage if pericardial effusion is present


  • It is pericarditis with concomitant myocardial inflammation but normal ventricular function
  • Most common causes are viral infections in developed countries while other infectious causes, eg TB, are common in developing countries
  • Management is similar to that of acute pericarditis: Exercise restriction, empiric Aspirin or NSAID therapy for chest pain and corticosteroids in cases of intolerance, contraindications or failure of Aspirin or NSAIDs
    • Data to recommend Colchicine use is insufficient

Purulent Pericarditis

  • May be due to a direct extension from bacterial pneumonia or pleural empyema 
  • Management is with surgical drainage of effusion and IV antibiotics
  • Dense adhesions and thick purulent effusions may require pericardiectomy for adequate drainage and prevention of constriction

Radiation Pericarditis

  • Acute pericarditis with or without effusion may develop following chest radiation
  • Management includes reduction in dose and volume of cardiac irradiation and pericardiectomy due to radiation-induced constrictive pericarditis

Systemic Autoimmune and Autoinflammatory Diseases

  • Pericardial involvement may be present in patients with Behcet’s syndrome, inflammatory bowel disease, rheumatoid arthritis, sarcoidosis scleroderma, Sjogren’s syndrome, systemic lupus erythematosus and systemic vasculitis
  • Treatment is with control of the systemic disease, may also consider anti-IL or anti-TNF therapeutic agents

Post-Cardiac Injury Syndromes

  • Autoimmune pathology in a group of pericardial syndromes which include post-MI pericarditis (Dressler syndrome), post-pericardiotomy syndrome, post-traumatic pericarditis
  • Treatment is based on empiric anti-inflammatory therapy

Pericarditis in Renal Failure

  • Has 3 different pathologies: Uremic pericarditis (pericarditis before dialysis or within 8 weeks of initiation of dialysis), dialysis pericarditis (occurs ≥8 weeks after initiation of dialysis) and constrictive pericarditis
  • Consider dialysis in uremic pericarditis and intensify dialysis for those patients who develop pericarditis despite ongoing renal replacement therapy


Acute Pericarditis

  • Long-term prognosis is good for patients with idiopathic or presumed viral pericarditis
  • Cardiac tamponade and constrictive pericarditis are more common in patients with underlying specific etiology
    • The possibility of constriction is related to the cause or etiology of pericarditis (eg TB or bacterial infection, cardiac surgery, trauma) and not to the number of episodes

Recurrent Pericarditis

  • Rates of complication are related to the cause or etiology and not to the frequency of recurrences
  • Severe complications and cardiac tamponade are rare while constrictive pericarditis has never been documented
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