Suspected Acute Pericarditis (Adult)
Pleuritic chest pain plus 1 or more: friction rub, diffuse ST elevation or PR depression, raised CRP/ESR, new pericardial effusion, pericardial inflammation on imaging. 2 or more = definite.
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Pericarditis Management (ACC 2025)
Pericarditis Management (ACC 2025): Suspected Acute Pericarditis (Adult) → Initial Assessment: ECG, Bloods, Echo → High-Risk Features? → High Risk: Admi...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Initial Assessment: ECG, Bloods, Echo
Exclude ACS, PE and aortic dissection first
- 12-lead ECG and troponin
- CRP, ESR, FBC, kidney and liver function
- Chest X-ray
- Transthoracic echo: effusion, tamponade, LV function
03Decision High-Risk Features?
Fever >38 °C, subacute onset, large effusion or tamponade, no response to NSAID after 1 week, raised troponin (myopericarditis), immunosuppression, trauma, oral anticoagulant
- If Yes
04Action High Risk: Admit to Hospital
Find and treat the cause. If idiopathic or viral: give the drug cautions and aspirin or NSAID plus colchicine steps below, started in hospital, then the same remission checks.
- Tamponade: urgent pericardiocentesis. Trauma, aortic dissection or cardiac rupture: emergency surgery (drain only small amounts as a bridge)
- Suspected bacterial or TB: pericardial fluid analysis and specific therapy
- Raised troponin (myopericarditis): exclude ACS (coronary angiography or CMR); cardiology sets exercise restriction
- Oral anticoagulant or trauma: watch for haemopericardium
05Outcome Follow-Up
Clinical review with CRP; echo as needed; CMR to guide therapy in recurrent disease
If No06Warning Drug Cautions Before Aspirin, NSAID or Colchicine
Low risk: treat as outpatient. High risk (idiopathic or viral): treat in hospital. Adult doses only. Children and pregnancy: specialist advice first.
- Colchicine: not if CrCl <30 mL/min, dialysis or severe liver impairment; not with clarithromycin, azoles, ritonavir or ciclosporin if any kidney or liver impairment; reduce dose with verapamil or diltiazem
- NSAIDs: not if NSAID or aspirin allergy; avoid or lowest dose in heart failure, CKD, peptic ulcer, bleeding risk or anticoagulant; ischaemic heart disease or recent MI: aspirin, not other NSAIDs
- Pregnancy: no NSAIDs from 20 weeks; colchicine only on specialist advice
07Action Aspirin or NSAID Plus Colchicine
Outpatient only if no high-risk feature (no tamponade, large effusion or fever >38 °C). Adult doses.
- Aspirin 500-1000 mg 8-hourly (for example 900 mg = 3 x 300 mg tablets) OR ibuprofen 600-800 mg 8-hourly
- Full dose until pain resolves and CRP normal (usually 1-2 weeks), then taper weekly
- PLUS colchicine 0.5 mg twice daily for 3 months; 0.5 mg once daily if <70 kg, older patient or CrCl 30-50 mL/min
- PPI for gastric protection
08Action Restrict Exercise for at Least 1 Month
Until remission: keep heart rate below 100/min
- No strenuous exercise
- Athletes: return to competition only after remission, with cardiology review
09Decision Remission on First-Line Therapy?
Remission: no symptoms and normal CRP. No: incessant (>4-6 weeks), recurrent (new flare after 4-6 weeks without symptoms) or intolerant.
- If Yes
10Action Remission: Taper and Complete Colchicine
Taper aspirin or NSAID weekly. Stop colchicine last: after 3 months in total (first episode) or at least 6 months (recurrence).
- Path rejoins step 05Shared downstream outcome
If No11Warning No Remission or Recurrence: Refer to Cardiology
Confirm adherence and dose. Look again for a specific cause.
- First recurrence: restart aspirin or NSAID plus colchicine; colchicine for at least 6 months
- Before steroid or anti-IL-1 agent: exclude TB and bacterial infection; screen hepatitis B and C and HIV
- CMR if recurrent or incessant: pericardial inflammation
12Decision Inflammatory Phenotype?
Only after failure of aspirin or NSAID plus colchicine. Inflammatory: raised CRP, fever, or pericardial inflammation (oedema or LGE) on CMR.
- If Yes
13Action Inflammatory (Raised CRP): Add Anti-IL-1 Agent
After failure of aspirin or NSAID plus colchicine. ACC 2025: preferred over steroids. ESC 2025: for recurrence that is steroid-dependent or not responding to colchicine.
- Adult: anakinra 100 mg SC once daily; every other day if CrCl <30 mL/min (off-label for pericarditis in Australia)
- Or rilonacept 320 mg SC once, then 160 mg SC weekly (US-approved; Australian supply not confirmed)
- Do not start if neutrophils <1.5 x 10^9/L, active infection or on a TNF inhibitor; no live vaccines
- Continue at least 12 months; keep colchicine; wean steroid then NSAID
14Action Refractory to Drugs: Consider Pericardiectomy
Radical pericardiectomy only at a high-volume pericardial surgery centre. Azathioprine or IVIG may be tried first.
- Path rejoins step 05Shared downstream outcome
If No15Action Not Inflammatory (Normal CRP): Low-Dose Steroid
After failure of aspirin or NSAID plus colchicine; also if an anti-IL-1 agent is not available or not suitable. Steroids raise the recurrence risk.
- Adult: prednisone 0.2-0.5 mg/kg/day (low to moderate dose), keep colchicine
- Hold dose until symptom-free and CRP normal, then taper slowly; below 10-15 mg/day reduce by 1-2.5 mg every 2-6 weeks
- Bone protection; PJP prophylaxis if >20 mg/day for 1 month or longer
- Steroid-dependent or relapse on taper: add anti-IL-1 agent
- Path rejoins step 14Shared downstream outcome
Guideline Source
2025 ACC Concise Clinical Guidance: Expert Consensus Statement on the Diagnosis and Management of Pericarditis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not cover purulent, tuberculous, neoplastic, post-cardiac-injury or constrictive pericarditis
- ACC 2025 and ESC 2025 differ on second line: anti-IL-1 agent (ACC, inflammatory phenotype) versus low-dose steroid (ESC)
- Myopericarditis and pericardial effusion are only triaged here, not managed
- Azathioprine, IVIG and pericardiectomy criteria are not detailed
Contraindicated Populations
pediatricpregnancy
Applicable Regions
USEUAU
AU: Colchicine tablets are 0.5 mg. Anakinra (Kineret) is TGA-registered for rheumatoid arthritis, CAPS and systemic JIA; use in pericarditis is off-label. Rilonacept: Australian supply not confirmed.
EU: ESC 2025 myocarditis and pericarditis guideline: low-dose corticosteroid stays second line after first-line failure; anti-IL-1 agents for recurrent pericarditis that is steroid-dependent or not responding to colchicine.
US: ACC 2025 concise clinical guidance: anti-IL-1 agent preferred over corticosteroid for recurrent pericarditis with inflammatory phenotype (raised CRP). Colchicine tablets are 0.6 mg (0.6 mg twice daily; once daily if <70 kg).
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Pericarditis Management (ACC 2025)?
The Pericarditis Management (ACC 2025) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2025 ACC Concise Clinical Guidance: Expert Consensus Statement on the Diagnosis and Management of Pericarditis.
What guideline is the Pericarditis Management (ACC 2025) based on?
This algorithm is based on 2025 ACC Concise Clinical Guidance: Expert Consensus Statement on the Diagnosis and Management of Pericarditis (DOI: 10.1016/j.jacc.2025.05.023).
What are the limitations of the Pericarditis Management (ACC 2025)?
Known limitations include: Does not cover purulent, tuberculous, neoplastic, post-cardiac-injury or constrictive pericarditis; ACC 2025 and ESC 2025 differ on second line: anti-IL-1 agent (ACC, inflammatory phenotype) versus low-dose steroid (ESC); Myopericarditis and pericardial effusion are only triaged here, not managed; Azathioprine, IVIG and pericardiectomy criteria are not detailed. Individual patient factors may require deviation from these recommendations.
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