The American College of Cardiology (ACC) recently released a 2025 guidance update regarding pericarditis, An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis: A Report of the American College of Cardiology Solution Set Oversight Committee. 

Click here to view the full text for an ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis.

This Concise Clinical Guidance (CCG) document focuses on the diagnostic and therapeutic advances in acute and recurrent pericarditis along with associated complications. The CCG is primarily targeted to cardiovascular care teams, rheumatologists, primary care physicians, emergency and internal medicine physicians, and cardiologists.

The following is a brief rundown of the guidance offered within the ACC’s CCG on diagnosing and managing pericarditis.

Key Elements of the 2025 Update:

Novel Clinical Diagnostic Criteria and Perspectives:

  • Pleuritic chest pain or equivalent must be noted along with one or more of the following:
    • Pericardial friction rub (<1/3) 
    • Electrocardiogram changes consisting of diffuse ST-segment elevation and/or PR-segment depression (up to 60%)
    • Inflammatory biomarkers elevation (such as C-reactive protein, sedimentation rate)
    • Cardiac imaging (especially echocardiography evidence) of new or worsening pericardial effusion (up to 60%)
    • Cardia imaging evidence of pericardial inflammation (especially CMR pericardial late gadolinium enhancement/edema, computed tomography as alternative)

Recommendations for Diagnostic Evaluation, Multimodality Cardiac Imaging, and Management for Pericarditis:

The following are all “Recommended” class statements in the CCG. For a full overview, including “Reasonable” and “Not Recommended” statements, view the full text.

  • Thorough history recording (including symptoms description and duration, risk factors, assessment of systemic inflammatory diseases), physical examination (auscultation of rubs), and ECG (for pericarditis changes) as part of evaluation for pericarditis
  • Assessment of the presence of systemic inflammation by means of C-reactive protein, fever, neutrophil leukocytosis, and presence of pericardial and pleural effusion to target specific treatments
  • TTE for evaluating and surveillance of pericardial effusion, signs of tamponade, constriction, and myocardial involvement of pericarditis
  • CMR for initial evaluation of pericarditis in terms of pericardial LGE, edema, thickening, effusion, signs of constriction, and myocardial involvement for diagnosis and risk stratification, especially for complicated/indeterminant cases
  • High-dose aspirin or NSAID in combination with colchicine (3 mo, acute; 6 mo, recurrent) as first-level therapies for pericarditis (aspirin is preferred in case of concomitant ischemic heart disease)
  • Anti–IL-1 agents in recurrent/incessant pericarditis after failure of first-level therapies and/or corticosteroids, especially with evidence of inflammatory phenotype
  • Exercise restriction for ≥1 mo after pericarditis diagnosis or flare (maximal heart rate <100 beats/min regardless of activity) until clinical remission

Therapeutic Option Recommendations for Acute and Recurring Pericarditis:

  • Aspirin, 500-1000 mg, 3x daily
  • Ibuprofen, 600-800 mg, 3x daily
  • Indomethacin, 25-50 mg, 3x daily
  • Colchicine, 0.6 mg 2x daily, or 0.6 mg 1x daily
  • Prednisone, 0.2-0.5 mg/kg/d
  • Anakinra, 1-2 mg/kg/d up to 100 mg/d in adults
  • Rilonacept, 320 mg once followed by 160 mg weekly
  • Goflikicept (not yet available in the United States), 80 mg every 2 weeks
  • Azathioprine, 1 mg/kg per day then gradually increased to 2-3 mg/kg/d
  • IVIG, 400 to 500 mg/kg/ IV daily for five days
  • Radical pericardiectomy, high-volume pericardial surgical center

Recommendations for Multimodality Cardiac Imaging Evaluation and Management for Pericardial Effusions and Cardiac Tamponade:

The following are all “Recommended” class statements in the CCG. For a full overview, including “Reasonable” and “Not Recommended” statements, view the full text.

  • TTE to identify pericardial effusion and assess for cardiac tamponade
  • CCT/CMR or transesophageal echocardiogram to confirm diagnosis of pericardial effusion when clinically indicated if TTE inconclusive
  • Transesophageal echocardiogram/CCT to confirm clinical diagnosis of focal cardiac tamponade in cases of high suspicion with unrevealing/equivocal TTE
  • Pericardiocentesis for cardiac tamponade

Recommendations for Multimodality Cardiac Imaging Evaluation and Management for Constructive Pericarditis:

The following are all “Recommended” class statements in the CCG. For a full overview, including “Reasonable” and “Not Recommended” statements, view the full text.

  • Noninvasive hemodynamic assessment by TTE for the diagnosis of constrictive pericarditis and effusive constrictive pericarditis
  • CMR to identify pericardial inflammation as an etiology of for constrictive pericarditis
  • Invasive cardiac catheterization for the diagnosis of constrictive pericarditis, where noninvasive methods are nondiagnostic or equivocal
  • First-line treatment of inflammatory constrictive pericarditis with anti-inflammatory therapy
  • Radical surgical pericardiectomy for noninflammatory constrictive pericarditis and inflammatory constrictive pericarditis failing anti-inflammatory therapy

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