EMA Cited · Cardiology · Chest pain

Pericarditis

Updated Oct 30, 2026Adults · ED management13 sources · 11 checked in PubMed2 figuresESC 2025

Bottom line

Diagnose with the presentation plus more than one supporting finding: a rub, PR depression or widespread ST elevation, a new or growing effusion, or a raised CRP.¹
Think of ACS first. Any ST depression in aVL was present in all 154 inferior STEMIs and none of 49 pericarditis ECGs in one ED study.⁵
Most patients go home. Admit those with high-risk features: fever over 38 °C, signs of tamponade, an effusion over 20 mm, NSAID failure, or incessant disease. See everyone else again within 1–2 weeks.¹
Full-dose aspirin or an NSAID plus colchicine (both Class I). Adding colchicine cut incessant or recurrent pericarditis from 37.5% to 16.7% (NNT 4).^1,7
Don't start with steroids unless there is a specific reason (Class III). Steroid use was an independent risk factor for recurrence (OR 4.30).^1,8

First steps

Assess everyone the same way: history, exam, ECG, chest X-ray, echo, and blood tests including CRP and troponin (Class I).¹
Think about ACS first. Use coronary angiography or coronary CT when ACS is suspected (Class I).¹
Look for high-risk features (table below). Any one means admission and a search for the cause.¹
Start treatment: full-dose aspirin or an NSAID every 8 hours with a proton pump inhibitor, plus colchicine.¹
Restrict exercise until remission, for at least 1 month (Class I).¹
Low risk: discharge with review in 1–2 weeks to check the response.¹

FIG 1 · Decision flowCited

Suspected pericarditis: history, exam, ECG, chest X-ray, echo, CRP and troponin.¹
Could this be ACS?
Yes
Coronary angiography or coronary CT to exclude obstructive disease.¹ ST depression in aVL points to inferior STEMI.⁵
No
Presentation plus more than one supporting finding?
No
Possible (one finding) or unlikely (none). CMR is recommended when clinical criteria can't settle the diagnosis.¹
Yes
Troponin raised or ECG changes?
Yes
Consider myocardial involvement and look for myocarditis.¹ Myopericarditis usually does well.⁶
Either way
Any high-risk feature?
Yes
Admit, search for the cause, and start anti-inflammatory therapy. Tamponade needs drainage.¹
No
Ibuprofen 600–800 mg or aspirin 750–1000 mg three times daily with a PPI, plus colchicine 0.5 mg twice daily (once daily under 70 kg or with severe renal impairment).¹
Restrict exercise until remission, for at least 1 month.¹
Good response at 1–2 weeks?
No
Reassess risk. Intermediate risk: admit or follow closely and look for a cause. High risk: admit.¹
Yes
Taper the NSAID or aspirin once symptoms and CRP settle. Continue colchicine for at least 3 months.¹

FIG 1Chest pain that looks like pericarditis. Drawn for this page from the 2025 ESC guideline and the trials cited below. Each box carries its own citations.^1,5,7

Diagnosis

Finding	How often	Notes
Clinical presentation
Chest pain	85–90%	Sharp and pleuritic. Better sitting up and leaning forward; worse on inspiration, lying flat and swallowing.¹
Additional criteria
Pericardial friction rub	≤ 33%	Scratchy or squeaking. Can disappear as an effusion builds.¹
ECG: PR depression, widespread ST elevation	Up to 60%	More common in young patients. Suggests the myocardium is involved too.¹
New or worsening effusion	Up to 60%	Usually mild. A normal echo does not rule out pericarditis.¹
Raised CRP	79–90%	Also a marker of disease activity, used to guide treatment length.¹

Definite: the clinical presentation plus more than one additional criterion. Possible: the presentation plus one. Unlikely: the presentation alone. Pericardial edema or late gadolinium enhancement on CMR also counts as a criterion.¹

The pericardium is electrically silent. The ESC reads ECG changes as a sign of myocardial inflammation and advises looking for myocarditis.¹
Myopericarditis is common and usually benign. It made up 14.6% of 274 viral or idiopathic cases. At 12 months, echo, ECG and treadmill tests were normal in 98%.⁶
ECG changes and troponin rise were usually not markers of a worse outcome when the patient had an infarct-like presentation but normal ventricular function.¹
Older patients more often report dyspnea than pain.¹

The ECG, and telling it from STEMI

12-lead ECG with mild widespread ST elevation, PR depression in lead II and PR elevation with ST depression in aVR — FIG 2Acute pericarditis. Mild ST elevation across many leads with PR depression (clearest in II), and the reverse in aVR: PR elevation with ST depression.James Heilman, MD · Wikimedia Commons · CC BY-SA 4.0

Typical pericarditis: concave ST elevation of about 0.5–1 mm in many leads, PR depression in the same leads, and ST depression with PR elevation in aVR (sometimes V1).⁴
Favors STEMI: ST depression anywhere other than aVR and V1, ST elevation higher in III than II, and convex or horizontal ST elevation.⁴
Check aVL. In one ED study, every inferior STEMI (154 of 154) had some ST depression in aVL, and no pericarditis ECG (0 of 49) did. It was present in 49 of 54 subtle inferior occlusion MIs.⁵
PR depression doesn't settle it. About 12% of STEMIs show it, and pain that changes with position or breathing occurs in STEMI too.⁴
The ECG evolves over weeks: ST elevation, then flat T waves, then T inversion, then normal. Fewer than half of patients go through every stage.⁴

Who to admit

Risk	Clinical	Imaging	Plan
High	Signs of tamponade; fever > 38 °C; effusive-constrictive pericarditis; NSAID failure; incessant pericarditis	Effusion > 20 mm at end-diastole; tamponade; extensive pericardial LGE on CMR	Admit, search for the cause, anti-inflammatory therapy
Intermediate	Signs of right heart failure	Effusion 10–20 mm; constrictive physiology	Admit or follow closely, and search for the cause
Low	Responds to therapy within 1–2 weeks	No or mild effusion; no pericardial LGE	Outpatient treatment

From the 2025 ESC risk table and triage flowchart. Admission for high-risk pericarditis is Class I, level B.¹

Where the high-risk features come from: in 453 prospectively followed patients, fever over 38 °C (HR 3.56), a subacute course (HR 3.97), a large effusion or tamponade (HR 2.15) and aspirin or NSAID failure (HR 2.50) predicted a specific underlying cause. A large effusion or tamponade (HR 2.51) and NSAID failure (HR 5.50) predicted complications.²
About 25% of patients have at least one poor-prognosis feature and need admission.¹
In-hospital mortality is about 1%. In a Finnish national registry it was 1.1%, rising with age (HR 3.26 per decade) and with severe co-infection such as pneumonia or sepsis.^1,3

Treatment

Drug	Adult dose	Duration	Taper	Notes
First line: pick one, plus colchicine
Ibuprofen	600–800 mg PO three times daily	1–2 weeks	200 mg every 1–2 weeks	Usually the first NSAID tried.¹
Aspirin	750–1000 mg PO three times daily	1–2 weeks	250 mg every 1–2 weeks	Preferred with ischemic heart disease or existing aspirin use.¹
Colchicine	0.5 mg PO twice daily; once daily if < 70 kg or severe renal impairment	≥ 3 months (≥ 6 if recurrent)	Not required	Class I, level A. Stop it last.¹
Proton pump inhibitor	With every aspirin or NSAID course	—	—	Recommended by the ESC.¹
Second line
Prednisone	0.2–0.5 mg/kg/day	2–4 weeks	Slow, over months	Only if aspirin/NSAIDs are contraindicated or fail, or for a specific indication (Class IIa).¹
Indomethacin	25–50 mg PO three times daily	1–2 weeks	25 mg every 1–2 weeks	Usually reserved for incessant or recurrent cases.¹

Unreviewed doses. Verify against the current label and your institution's protocol before giving anything.

Doses from the 2025 ESC guideline (Table 13). Keep the starting dose until symptoms resolve and CRP normalizes, then taper. With moderate to severe renal impairment, adjust the aspirin/NSAID dose or use a corticosteroid.¹

US colchicine tablets

The ESC doses colchicine in 0.5 mg steps. Colcrys tablets in the US are 0.6 mg, and the US label covers gout and familial Mediterranean fever, not pericarditis.^1,11 Dose per institutional protocol.

Colchicine

ICAP (n = 240, first episode, double-blind): incessant or recurrent pericarditis 16.7% vs 37.5% (NNT 4). Colchicine also halved symptom persistence at 72 hours (19.2% vs 40.0%) and cut hospitalization (5.0% vs 14.2%).⁷
COPE (n = 120, open-label): recurrence at 18 months 10.7% vs 32.3%. Diarrhea stopped colchicine in 8.3%.⁸
Cochrane (4 trials, 564 patients): colchicine reduced recurrence after acute pericarditis (HR 0.40, moderate quality). More patients stopped it for side effects, mostly GI (RR 1.87).⁹
Check interactions. Fatal colchicine toxicity has been reported with clarithromycin, a strong CYP3A4 inhibitor, and with cyclosporine, a P-gp inhibitor. With kidney or liver impairment, these combinations are contraindicated.¹¹

Corticosteroids

Not a first option without a specific indication (Class III, level C).¹ Specific indications include systemic inflammatory disease already on steroids, post-pericardiotomy syndromes, post-vaccine pericarditis, severe renal failure, and oral anticoagulation.¹
High doses with a fast taper raise the risk of recurrence or chronic disease. Avoid higher doses except briefly, and taper slowly, especially below 15 mg/day.¹
In COPE, steroid use was an independent risk factor for recurrence (OR 4.30).⁸

Activity and heart rate

Restrict exercise until remission, for at least 1 month, in athletes and non-athletes alike (Class I, level C). The ESC prefers an individual plan over fixed 3- to 6-month bans.¹
Consider a beta-blocker if symptoms persist despite full anti-inflammatory therapy and the resting heart rate is over 75 (Class IIa, level C).¹

Recurrent pericarditis

Recurrence is the most common complication: 20–30% of patients not treated with colchicine.¹
Colchicine still works after several recurrences. In CORP-2 (n = 240, ≥ 2 prior recurrences), recurrence was 21.6% vs 42.5% (NNT 5).¹⁰
When a recurrence happens on a steroid taper, continue colchicine and add an NSAID rather than raising the steroid dose.¹
Anti-IL-1 drugs (anakinra or rilonacept) are recommended after first-line drugs and steroids fail and CRP is raised (Class I, level A).¹
RHAPSODY: after a run-in on rilonacept, recurrence was 7% on continued rilonacept vs 74% on placebo.¹² AIRTRIP: recurrence was 18.2% on anakinra vs 90% on placebo, in 21 patients.¹³

Disposition

Low risk: treat as an outpatient and arrange review within 1–2 weeks.¹
No response at 1–2 weeks: reassess the risk. Intermediate risk means admission or close follow-up with a search for the cause; high risk means admission.¹
Expected course: remission within 4–6 weeks. Tamponade and constriction each occur in under 1% of acute pericarditis.¹
Bacterial pericarditis is different: the risk of constriction is 20–30%, especially if purulent.¹

Pitfalls

Calling an inferior STEMI pericarditis. Look for ST depression in aVL.^4,5
Giving NSAIDs at analgesic doses instead of full anti-inflammatory doses every 8 hours.¹
Leaving out colchicine, a key risk factor for recurrence.^1,7
Starting prednisone first-line, or at high dose with a fast taper.^1,8
Prescribing colchicine alongside clarithromycin or another strong CYP3A4 or P-gp inhibitor.¹¹
Discharging a febrile patient or one with a large effusion.¹

How strong is the evidence?

Colchicine has the strongest support: several randomized trials and a Cochrane review, rated level A by the ESC.^1,7,9 Aspirin and NSAIDs are level B.¹ Advice on steroids, exercise and beta-blockers is expert opinion (level C).¹ The anti-IL-1 trials were small, randomized-withdrawal designs in selected patients.^12,13

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1What makes a diagnosis of pericarditis definite under the 2025 ESC criteria?

The clinical presentation plus more than one additional criterion: a rub, PR depression or widespread ST elevation, a new or growing effusion, a raised CRP, or pericardial inflammation on CMR.¹

Q2Inferior ST elevation and pleuritic pain. Which single lead helps most?

aVL. Some ST depression there was present in all 154 inferior STEMIs and in none of 49 pericarditis ECGs.⁵

Q3Why add colchicine to the NSAID for a first episode?

In ICAP, it cut incessant or recurrent pericarditis from 37.5% to 16.7% (NNT 4) and halved symptom persistence at 72 hours.⁷

Q4Which patients need admission?

Those with a high-risk feature: signs of tamponade, fever over 38 °C, effusive-constrictive pericarditis, NSAID failure, incessant disease, or an effusion over 20 mm.¹

Q5Why not just give prednisone?

The ESC recommends against steroids first-line without a specific indication (Class III).¹ In COPE, steroid use independently predicted recurrence (OR 4.30).⁸

Q6The ECG shows PR depression and the troponin is up. What does that change?

The ESC reads ECG changes as myocardial involvement and advises looking for myocarditis.¹ Myopericarditis is usually benign: 98% had normal tests at 12 months in one cohort.⁶

References

Evidence base

What this page is built on

13 sources, cited 92 times. Dots are sources, filled by how far each was read; stronger color means a larger share of the citations. Tap a tier to see its sources.

Read in full · 3Abstract read · 10Record only · 0Link checked · 0

Checked by the writer, not a physician. The dots show how each source was read, not that anyone has confirmed the claims.

1
Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46(40):3952–4041.GuidelinePMID 40878297 DOIFull text read
2
Imazio M, Cecchi E, Demichelis B, et al. Indicators of poor prognosis of acute pericarditis. Circulation. 2007;115(21):2739–2744.CohortPMID 17502574PubMed
3
Kytö V, Sipilä J, Rautava P. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation. 2014;130(18):1601–1606.RegistryPMID 25205801PubMed
4
Life in the Fast Lane. Pericarditis ECG library.FOAMlitfl.comPage read
5
Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149–154.Diagnostic studyPMID 26542793PubMed
6
Imazio M, Cecchi E, Demichelis B, et al. Myopericarditis versus viral or idiopathic acute pericarditis. Heart. 2008;94(4):498–501.CohortPMID 17575329PubMed
7
Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis (ICAP). N Engl J Med. 2013;369(16):1522–1528.RCTPMID 23992557PubMed
8
Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005;112(13):2012–2016.RCTPMID 16186437PubMed
9
Alabed S, Cabello JB, Irving GJ, Qintar M, Burls A. Colchicine for pericarditis. Cochrane Database Syst Rev. 2014;(8):CD010652.Meta-analysisPMID 25164988 PMCPubMed
10
Imazio M, Belli R, Brucato A, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2). Lancet. 2014;383(9936):2232–2237.RCTPMID 24694983PubMed
11
Colcrys (colchicine) tablets. US prescribing information. DailyMed.Drug labeldailymed.nlm.nih.govLabel text read
12
Klein AL, Imazio M, Cremer P, et al. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis (RHAPSODY). N Engl J Med. 2021;384(1):31–41.RCTPMID 33200890PubMed
13
Brucato A, Imazio M, Gattorno M, et al. Effect of anakinra on recurrent pericarditis among patients with colchicine resistance and corticosteroid dependence: the AIRTRIP randomized clinical trial. JAMA. 2016;316(18):1906–1912.RCTPMID 27825009PubMed

Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms