Pericarditis III: Medical Management

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin are the first-line treatments for pericarditis. These medications relieve pain and reduce inflammation effectively. For cases lasting more than ten days or recurrent episodes, colchicine is recommended as an adjunctive therapy to lower recurrence rates and manage severe inflammation.

Non-pharmacologic therapy includes advising patients to sit up, lean forward, and rest, which helps relieve pain and reduces metabolic demand on the heart. Bed rest is particularly important when cardiac output is impaired, allowing critical symptoms such as fever, chest pain, and pericardial friction rub to subside while the heart recovers.

Corticosteroids like prednisone are used as alternative medications for patients unresponsive to NSAIDs or colchicine. They effectively reduce inflammation but must be used cautiously due to possible side effects and the risk of recurrence. Corticosteroids are particularly useful when NSAIDs are contraindicated, such as in patients with kidney disease.

Pericardiocentesis is an invasive procedure involving needle removal of pericardial fluid. It is performed when significant pericardial effusion is present, especially with signs of cardiac tamponade or heart failure. The procedure may also identify the underlying cause through fluid culture or cytology if bacterial, tubercular, fungal, or neoplastic disease is suspected.

Pericardiectomy, the surgical removal of the pericardium, is necessary for constrictive pericarditis where the pericardium becomes thickened and restricts heart function. This procedure releases both ventricles from constrictive and restrictive inflammation and scarring, improving cardiac function. A pericardial window may also be created to allow continuous fluid drainage into the chest cavity for recurrent effusions.

The primary objectives are to determine the underlying cause, provide effective therapy for treatment and symptom relief, and promptly detect signs of cardiac tamponade. Identifying causes such as viral infections, autoimmune diseases, post-cardiac injury syndrome, or malignancies enables targeted treatment. Early recognition of complications prevents life-threatening outcomes and ensures positive patient outcomes.

While NSAIDs are first-line agents for acute pain and inflammation, colchicine serves as adjunctive therapy for severe cases or prolonged pericarditis lasting more than ten days. Colchicine specifically helps reduce inflammation and significantly lowers the recurrence rate of pericarditis episodes, making it valuable for preventing future attacks in susceptible patients.