Pericarditis
Aiya Almogaber, PharmD
A recent expert consensus statement from the American College of Cardiology (ACC) is reshaping how clinicians diagnose and manage pericarditis. Published in The Journal of the American College of Cardiology on August 6, 2025, the guidance highlights advanced multimodality imaging, refined diagnostic criteria, and expanded use of interleukin-1 (IL-1) inhibitors for recurrent disease, marking the first major update since 2015.
Pericarditis, an inflammation of the pericardial sac surrounding the heart, accounts for up to 5% of emergency department chest pain presentations and 0.1% of hospital admissions. The recent consensus statement modernizes diagnosis and treatment by moving beyond clinical findings to an imaging guided phenotype-specific approach.
ACC now requires pleuritic chest pain plus at least one objective feature, such as ECG changes, elevated inflammatory markers, or imaging evidence of inflammation for a definite diagnosis. This represents a shift from the 2015 European Society of Cardiology criteria, which relied heavily on auscultation and electrocardiography alone.
Pericarditis is also classified by duration: acute (<4–6 weeks), incessant (>4–6 weeks without remission), recurrent (new episode after a symptom free interval over 4 weeks), and chronic (>3 months). Recognizing the inflammatory phenotype, defined by elevated C-reactive protein and imaging evidence of edema, is crucial for tailoring therapy.
The 2025 ACC statement reframes pericarditis as an immune-mediated disorder requiring precision medicine rather than a uniform anti-inflammatory sequence. By integrating imaging biomarkers, phenotype classification, and targeted biologic therapy, clinicians can individualize treatment and reduce the burden of recurrent disease.
The guidance offers a clear, evidence-based road map and a reminder that persistent chest pain may demand not just another NSAID, but a deeper look at the pericardium itself.
Imaging takes center stage
Echocardiography remains the first-line tool for evaluating pericardial effusion and constrictive physiology, but cardiac magnetic resonance has become essential for confirming active inflammation.
Findings such as late gadolinium enhancement and T2-weighted edema imaging can help differentiate acute or recurrent inflammation from chronic fibrosis. Cardiac computed tomography plays a corresponding role in identifying pericardial thickening, and together, these modalities refine risk stratification and guide therapy escalation.
The recent guidance document is part of ACC’s “solution set” initiative, a model that integrates concise clinical guidance with decision tools and care pathway templates.
It encourages collaboration among cardiologists, rheumatologists, radiologists, pharmacists, and specialized pericardial disease centers (PDCs). These centers coordinate imaging, follow up, and therapy adjustments to reduce variability and improve outcomes for patients with recurrent or refractory disease.
The consensus guideline highlights PDCs as models of multidisciplinary coordination. Routine follow up every 3 months during active disease and 6 to 12 months when stable is recommended in the recent guidance. PDCs standardize evaluation, imaging, and long-term monitoring while providing patient education and rapid intervention during flares.
Pharmacists play an increasing role in preventing drug–drug interactions with colchicine (via CYP3A4 and P-glycoprotein pathways), counseling on IL-1 inhibitor adherence, and managing glucocorticoid tapering to prevent relapse.
Core medical therapy remains with nuance
High-dose aspirin or NSAIDs combined with colchicine remain the standard first-line regimen for pericarditis. ACC advises a 3-month course of colchicine for acute pericarditis and 6 months for recurrent disease, along with acid suppression to protect the GI tract. Exercise restriction for roughly 1 month while maintaining a maximum heart rate below 100 beats per minute is also recommended until clinical remission.
Corticosteroids are no longer routine second-line therapy. Instead, their use is reserved for noninflammatory or autoimmune phenotypes when other options are ineffective or contraindicated. When prescribed, the consensus emphasizes low to moderate doses (prednisone 0.2 to 0.5 mg/kg/day) with slow tapering over several months to minimize relapse risk.
Biologics redefine refractory care
The most notable update is the elevation of IL-1–blockage, specifically rilonacept and anakinra, to preferred status for patients with recurrent or steroid-dependent pericarditis. Randomized trials such as RHAPSODY demonstrated that IL-1 inhibitors significantly reduced recurrence and improved quality of life with favorable safety profiles. These agents target the inflammasome-mediated cytokine cascade at the core of the disease’s pathophysiology. ■