Acute pericarditis — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 26-year-old man presents to the emergency department with 3 days of sharp chest pain that is worse lying flat and on inspiration, and better sitting forward. A friction rub is heard. His ECG shows widespread ST-segment elevation and PR depression. His temperature is 38.4 °C and his C-reactive protein is elevated. Echocardiography shows a 7 mm pericardial effusion.^[1]

1. State the ESC 2025 rule for a definite clinical diagnosis of pericarditis, and name the additional criteria present here. (2)^[1]
2. How did the 2015 ESC guideline make the diagnosis, and why does ESC 2025 say his ECG changes matter? (2)^[2][1]
3. Grade his effusion by size and state how ESC 2025 measures it. (2)^[1]
4. Classify his risk using ESC 2025 Table 7 and state the disposition, with class and level. (2)^[1]
5. Which ECG pattern would instead point to an acute coronary pathology, and what imaging does ESC 2025 recommend if an ACS is suspected? (2)^[5][1]

Model answers — SAQ 1

1. ESC 2025: a definite clinical diagnosis needs a clinical presentation and more than one additional criterion (Table 4) (1 mark).^[1] He has at least three additional criteria: pericardial rub (clinical); PR depression with widespread ST-segment elevation (ECG); and C-reactive protein elevation (biomarkers); the 7 mm effusion is a further imaging criterion if it is new or worsening (Table 4) (1 mark).^[1]
2. The 2015 ESC guideline, now history, needed two of four criteria: chest pain, pericardial friction rub, ECG changes and pericardial effusion (1 mark).^[2] ESC 2025 says the pericardium is electrically silent, so ECG changes imply concomitant inflammation of the myocardium and warrant investigation for concurrent myocarditis (1 mark).^[1]
3. A 7 mm effusion is mild: ESC 2025 Table 10 grades mild as under 10 mm, moderate 10–20 mm and large over 20 mm (1 mark).^[1] Size is the end-diastolic distance of the echo-free space between the epicardium and the parietal pericardium (maximal end-diastolic diameter) (1 mark).^[1]
4. Fever above 38 °C is a high-risk feature in the pericarditis row of ESC 2025 Table 7, even though a mild effusion is a low-risk imaging feature (1 mark).^[1] Hospital admission is recommended for patients with high-risk pericarditis for monitoring and treatment (Class I, Level B), with an aetiology search (1 mark).^[1]
5. The Fifth UDMI (2026) describes ST-segment elevation with an acute coronary pathology as typically regional and often accompanied by reciprocal ST-segment depression; in pericarditis it is often diffuse or global without reciprocal changes (1 mark).^[5] ESC 2025: invasive coronary angiography or coronary CT, depending on clinical likelihood, is recommended in patients with IMPS if an ACS is suspected, to rule out obstructive coronary artery disease (Class I, Level C) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 39-year-old woman weighing 62 kg, with normal renal function, has a first episode of acute pericarditis without high-risk features and is managed as an outpatient. Eight months after stopping all therapy, and after a symptom-free interval, she has a recurrence.^[1]

1. Give the ESC 2025 first-line drug rows for her first episode, with class and level. (2)^[1]
2. State the Table 13 dose and duration of colchicine for her, and of one first-line anti-inflammatory drug. (2)^[1]
3. What do ESC 2025 and the COPE trial say about corticosteroids in a first episode? (2)^[1][6]
4. Define recurrent pericarditis under ESC 2025, and state how long colchicine is used for recurrent cases. (2)^[1]
5. Her later recurrences continue despite colchicine, NSAID and corticosteroids, with an elevated C-reactive protein. What does ESC 2025 recommend, and what did RHAPSODY show? (2)^[1][10]

Model answers — SAQ 2

1. High-dose aspirin or NSAIDs with proton pump inhibitors as first-line therapy, to control symptoms and reduce recurrences (Class I, Level B) (1 mark).^[1] Colchicine as first-line therapy, as an adjunct to aspirin/NSAID or corticosteroid therapy, to reduce subsequent recurrences (Class I, Level A) (1 mark).^[1]
2. Colchicine 0.5 mg once daily because she weighs under 70 kg, for 3–6 months, with tapering not required (1 mark).^[1] Ibuprofen 600–800 mg three times daily for 1–2 weeks, decreasing by 200 mg every 1–2 weeks; or aspirin 750–1000 mg three times daily for 1–2 weeks, decreasing by 250 mg every 1–2 weeks (1 mark).^[1]
3. ESC 2025: corticosteroids are not recommended as the first option for pericarditis therapy without a specific indication (Class III, Level C) (1 mark).^[1] In COPE (120 patients with a first episode of acute pericarditis, open-label), corticosteroid use was an independent risk factor for recurrence (OR 4.30) (1 mark).^[6]
4. Recurrent pericarditis is a relapse after a documented first episode of acute pericarditis, a symptom-free interval, complete discontinuation of anti-inflammatory therapy, and evidence of subsequent recurrence (1 mark).^[1] ESC 2025 Figure 16 says to consider colchicine for at least 6 months in incessant or recurrent cases, withdrawn as the last drug only after stable remission (1 mark).^[1]
5. Anti-IL-1 agents (anakinra or rilonacept) are recommended for recurrent pericarditis after failure of first-line therapies and corticosteroids and elevation of C-reactive protein, to reduce recurrences and allow corticosteroid withdrawal (Class I, Level A) (1 mark).^[1] RHAPSODY (phase 3, double-blind, randomised-withdrawal; recurrent pericarditis with elevated CRP): recurrence in 2 of 30 patients (7%) on rilonacept versus 23 of 31 (74%) on placebo (1 mark).^[10]