First episode of acute pericarditis and its recurrence — case discussion

Presentation

Practice case (not a real patient). A 23-year-old man in Sydney presents to the emergency department with 2 days of sharp chest pain that is worse lying down and on deep inspiration, and eased by sitting up and leaning forward.^[1] He is afebrile (37.2 °C), with normal blood pressure and no signs of tamponade or right heart failure.^[1] His ECG shows widespread ST-segment elevation with PR depression, and his C-reactive protein is elevated; troponin is normal.^[1] Echocardiography shows normal ventricular function and no pericardial effusion. He weighs 75 kg and has normal renal function.^[1]

Step 1 — Is this pericarditis, and is it a STEMI?

Discussion:

• ESC 2025 makes a definite clinical diagnosis with a clinical presentation and more than one additional criterion; he has two (the ECG changes and the CRP elevation).^[1]
• A normal-appearing echocardiogram does not exclude it: ESC 2025 reports this in 40%–50% of first episodes.^[1]
• The Fifth UDMI (2026) describes ST elevation in pericarditis as often diffuse or global without reciprocal changes, while with an acute coronary pathology it is typically regional and often accompanied by reciprocal ST depression.^[5]
• If an ACS were suspected, ESC 2025 recommends invasive coronary angiography or coronary CT, depending on clinical likelihood, to rule out obstructive coronary artery disease (Class I, Level C).^[1]

Step 2 — Admit or manage as an outpatient?

Discussion:

• He has none of the ESC 2025 Table 7 high-risk clinical features: no signs of tamponade, no fever above 38 °C, no effusive–constrictive pericarditis, no failure of NSAID therapy and no incessant course; on imaging, with no effusion, he has no large effusion (>20 mm end-diastole).^[1]
• ESC 2025 says patients without high-risk features can be managed as outpatients without an aetiology search and admission if there is a good response to empirical anti-inflammatory therapy, with close follow-up within 1 to 2 weeks.^[1]
• Routine serology is not recommended for viral aetiology, except for hepatitis C, HIV and Lyme disease (ESC 2025, Class III, Level C).^[1]

Step 3 — Treatment

Discussion:

• High-dose aspirin or an NSAID with a proton pump inhibitor is first-line, to control symptoms and reduce recurrences (ESC 2025, Class I, Level B); Table 13 gives ibuprofen 600–800 mg three times daily for 1–2 weeks, decreasing by 200 mg every 1–2 weeks.^[1]
• Colchicine is added as first-line adjunct therapy to reduce subsequent recurrences (ESC 2025, Class I, Level A); at 75 kg with normal renal function, Table 13 gives 0.5 mg twice daily for 3–6 months, tapering not required.^[1]
• Corticosteroids are not recommended as the first option without a specific indication (ESC 2025, Class III, Level C).^[1]
• ESC 2025 recommends restriction of physical exercise until remission, for at least 1 month, in athletes and non-athletes after IMPS, using an individualised approach to accelerate recovery (Class I, Level C).^[1]

Step 4 — Review at 10 days

He returns at 10 days, pain-free, with a falling C-reactive protein.^[1]

• ESC 2025 says the attack dose is maintained until symptoms resolve and inflammatory markers and other investigations normalise, and then tapering is recommended.^[1]
• In pericarditis, ESC 2025 calls CRP a marker of disease activity that could be used to guide the duration of anti-inflammatory therapy.^[1]
• In uncomplicated cases, clinical follow-up with or without echocardiography is sufficient (ESC 2025).^[1]
• Return to sport should be individualised: ESC 2025 says complete clinical remission should be considered with normalisation of symptoms, biomarkers and imaging.^[1]

Step 5 — A recurrence

Ten months after completing therapy, and after a symptom-free interval, his pain returns with a raised C-reactive protein.^[1]

• This meets the ESC 2025 definition of recurrent pericarditis: a relapse after a documented first episode, a symptom-free interval, complete discontinuation of anti-inflammatory therapy and evidence of recurrence.^[1]
• ESC 2025 says the mainstay is always colchicine with aspirin or an NSAID, or with low to moderate doses of corticosteroids, and colchicine for at least 6 months in recurrent cases.^[1]
• Treatment duration with aspirin or NSAIDs and corticosteroids should be extended in an individualised way, and tapering should be slower than for a first episode (ESC 2025).^[1]
• After failure of first-line therapies and corticosteroids, with an elevated C-reactive protein, anti-IL-1 agents (anakinra or rilonacept) are recommended for recurrent pericarditis to reduce recurrences and allow corticosteroid withdrawal (ESC 2025, Class I, Level A).^[1]
• Long-term follow-up is recommended for recurrent pericarditis to identify a potential progression and new complications (ESC 2025, Class I, Level C).^[1]

Learning points

• Definite pericarditis needs a clinical presentation plus more than one additional criterion (ESC 2025).^[1]
• Patients without high-risk features can be managed as outpatients if there is a good response to empirical anti-inflammatory therapy, with close follow-up within 1 to 2 weeks (ESC 2025).^[1]
• High-dose aspirin or an NSAID with a proton pump inhibitor is first-line, to control symptoms and reduce recurrences, with colchicine as a first-line adjunct to reduce subsequent recurrences; corticosteroids are not the first option without a specific indication (ESC 2025).^[1]
• In Australia, a New South Wales cohort found in-hospital mortality of about 1% when pericardial disease was the primary diagnosis.^[14]