TABLE 4.

Current Treatment Paradigm³

Stage of Pericarditis	Acute	First Recurrence	Multiple Recurrences	Colchicine-resistant or Steroid-dependent	Constrictive
Imaging	Echocardiogram for pericardial effusion, myocardial involvement, constriction	Echocardiogram for constriction CMR in select cases for pericardial inflammation or constriction	Same as for “first recurrence”	Same as for “first recurrence”	Same as for “first recurrence”Plus possible computed tomography for extent of calcification and preoperative planning
Treatment	NSAIDs (wk)Colchicine (3 mo)	NSAIDs (wk to mo)Colchicine (≥6 mo)	NSAIDs + colchicine + prednisone (>6 mo, taper steroid as tolerated)Consider steroid-sparing agent (warrants further study)	NSAIDs + colchicine + prednisone + steroid-sparing agent (6–12 mo, taper steroid as tolerated)Consider pericardiectomy (warrants further study)	Intensify medical therapy if inflamedPericardiectomy if “burnt out”

All patients with acute pericarditis should have an echocardiogram for short-term risk stratification, and subsequent echocardiograms can be performed if there is concern for constrictive pericarditis. In recurrent pericarditis, cardiac magnetic resonance imaging has an emerging role to assess for pericardial inflammation if the clinical evaluation is equivocal and to assess for constrictive pathophysiology if the echocardiogram is indeterminate. Computed tomography is primarily employed to assess pericardial calcification and for preoperative planning. The mainstay of treatment is NSAIDs and colchicine with the addition of low-dose corticosteroids in patients with multiple recurrences. Steroid-sparing agents can be added in refractory cases. Early use of steroid-sparing agents and pericardiectomy for recurrent pericarditis may be beneficial and warrants further study.

NSAIDs indicates nonsteroidal antiinflammatory drugs.