Acute pericarditis — viva

Stem

Practice viva. The examiner describes a young adult with pleuritic chest pain and widespread ST elevation, and works through the diagnosis of pericarditis, triage, first-line treatment with colchicine, recurrence, and pericarditis after myocardial infarction or cardiac surgery.^[1]

Branch A — Making the diagnosis

Examiner: How do you diagnose acute pericarditis under the 2025 ESC guideline?^[1]

Strong answer:

• ESC 2025 defines acute pericarditis as an inflammatory pericardial syndrome with or without pericardial effusion and an onset of 4 weeks or less.^[1]
• A definite clinical diagnosis needs a clinical presentation and more than one additional criterion; one additional criterion makes it possible.^[1]
• The additional criteria are pericardial rubs; PR depression, widespread ST-segment elevation on the ECG; C-reactive protein elevation; and new or worsening pericardial effusion, or pericardial oedema and/or LGE on CMR.^[1]
• The 2015 ESC guideline, now history, used two of four criteria.^[2]

Follow-up: The ECG is abnormal. What does that tell you?^[1]

• ESC 2025 says the pericardium is electrically silent, so ECG changes imply concomitant inflammation of the myocardium and warrant investigation for concurrent myocarditis.^[1]
• Troponin may be elevated in 20%–30% of cases because of concomitant myocarditis (myopericarditis), and patients with myopericarditis can be treated as patients with pericarditis.^[1]
• The Fifth UDMI (2026) says ST-segment elevation in pericarditis is often diffuse or global and without reciprocal changes, whereas with an acute coronary pathology it is typically regional and often accompanied by reciprocal depression.^[5]

Branch B — Admit or discharge?

Examiner: Who needs admission?^[1]

Strong answer:

• ESC 2025: hospital admission is recommended for patients with high-risk pericarditis for monitoring and treatment (Class I, Level B).^[1]
• High-risk features in ESC 2025 Table 7 are signs and symptoms of cardiac tamponade, fever above 38 °C, effusive–constrictive pericarditis, failure of NSAID therapy and incessant pericarditis, with imaging criteria of a large effusion over 20 mm at end-diastole, tamponade or extensive pericardial LGE on CMR.^[1]
• Non-high-risk cases can be managed as outpatients with close follow-up within 1 to 2 weeks.^[1]
• ESC 2025 reports that approximately 25% of patients with acute pericarditis present with at least one predictor of poor prognosis and require hospitalisation.^[1]

Follow-up: What are the major red flags in Table 16?^[1]

• Fever above 38 °C (HR 3.56), subacute onset (HR 3.97), a large effusion over 20 mm on echocardiography (HR 2.15), cardiac tamponade (HR 2.15), and lack of response to aspirin or an NSAID after at least 1 week of therapy (HR 2.50).^[1]
• ESC 2025 says these major features were validated in multivariable analysis in a prospective cohort study of patients with acute pericarditis.^[1]

Branch C — Treating the first episode

Examiner: What do you prescribe, and at what dose?^[1]

Strong answer:

• ESC 2025: high-dose aspirin or NSAIDs with proton pump inhibitors as first-line therapy, to control symptoms and reduce recurrences (Class I, Level B).^[1]
• ESC 2025: colchicine as first-line therapy, as an adjunct to aspirin/NSAID or corticosteroid therapy, to reduce subsequent recurrences (Class I, Level A).^[1]
• Table 13: aspirin 750–1000 mg three times daily or ibuprofen 600–800 mg three times daily for 1–2 weeks with tapering; colchicine 0.5 mg twice daily, or once daily under 70 kg or with severe renal impairment, for 3–6 months, tapering not required.^[1]
• ESC 2025: restriction of physical exercise until remission, for at least 1 month, is recommended in athletes and non-athletes after IMPS using an individualised approach to accelerate recovery (Class I, Level C).^[1]

Follow-up: What is the evidence for colchicine?^[1]

• ICAP (multicentre, double-blind; 240 adults with acute pericarditis; colchicine for 3 months added to aspirin or ibuprofen): incessant or recurrent pericarditis 16.7% versus 37.5% with placebo, number needed to treat 4.^[7]
• COPE (open-label; 120 patients with a first episode): recurrence at 18 months 10.7% with colchicine versus 32.3% with conventional treatment with aspirin.^[6]
• ESC 2025 says colchicine on top of anti-inflammatory therapy is supported by most of the published evidence, with the single exception of a small open-label trial that was probably underpowered.^[1]

Branch D — When it comes back

Examiner: The pericarditis comes back months later. How do you manage recurrent pericarditis?^[1]

Strong answer:

• ESC 2025 says the mainstay is always colchicine with aspirin or an NSAID, or with low to moderate doses of corticosteroids; colchicine for at least 6 months in incessant or recurrent cases.^[1]
• A patient who recurs during corticosteroid tapering should continue colchicine and receive an NSAID on top, instead of an increased corticosteroid dose.^[1]
• Anti-IL-1 agents (anakinra or rilonacept) are recommended for recurrent pericarditis after failure of first-line therapies and corticosteroids with elevated C-reactive protein, to reduce recurrences and allow corticosteroid withdrawal (Class I, Level A).^[1]
• Anti-IL-1 agents should be considered in incessant or recurrent pericarditis with evidence of pericardial inflammation on CMR after failure, contraindications and intolerance to first-line therapies and corticosteroids, regardless of C-reactive protein levels, to reduce recurrences and allow corticosteroid withdrawal (Class IIa, Level C).^[1]
• ESC 2025: long-term follow-up is recommended for incessant or recurrent pericarditis to identify a potential progression and new complications (Class I, Level C).^[1]

Follow-up: Which trials support anti-IL-1 agents?^[10][11]

• RHAPSODY (phase 3, randomised-withdrawal; recurrent pericarditis with elevated CRP): recurrence in 7% on rilonacept versus 74% on placebo.^[10]
• AIRTRIP (21 patients with 3 or more recurrences, elevated C-reactive protein, colchicine resistance and corticosteroid dependence; randomised withdrawal): recurrence in 18.2% on anakinra versus 90% on placebo; the investigators call it preliminary.^[11]

Branch E — After infarction and after surgery

Examiner: How does pericarditis after an MI or cardiac surgery differ?^[1]

Strong answer:

• The 2023 ESC ACS guideline separates early infarct-associated pericarditis (a few hours to 4 days after acute MI, mostly transient) from Dressler syndrome (typically 1–2 weeks after acute MI).^[3]
• ESC 2025: high-dose aspirin is the first-choice anti-inflammatory therapy for post-MI pericarditis and in patients already on antiplatelet therapy (Class I, Level C).^[1]
• The ACC/AHA 2025 ACS guideline calls glucocorticoids and NSAIDs other than aspirin potentially harmful after MI (no class or level given).^[4]
• After cardiac surgery, ESC 2025 says colchicine, started 48 to 72 h before surgery, should be considered for 1 month to prevent PCIS if there are no contraindications and it is tolerated (Class IIa, Level A).^[1]