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cardio.pericarditis.core.v1PRODUCTION
cardio.pericarditis.core.v1

Pericarditis (acute / recurrent / IMPS)

cardiologyacutesubacutechronicadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute (<4–6 wk), incessant (4–12 wk), recurrent (≥1 month-free interval), chronic; IMPS framework (ACC/AHA 2022)

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Patient inputs (13)

Age + first vs recurrent class affects dose / taper (ACC/AHA 2022)

Tachycardia from inflammation / tamponade (ACC/AHA 2022)

Diffuse ST↑ + PR↓ supports diagnosis (≥2 of 4 ESC criteria)

Detect effusion + tamponade (ACC/AHA 2022)

Myopericarditis screen (RHAPSODY uses CRP+CMR+troponin) (ACC/AHA 2022)

Diagnostic + treatment-response biomarker (ACC/AHA 2022)

Tamponade physiology screen (Beck triad) (ACC/AHA 2022)

Colchicine/NSAID dose adjustment (ACC/AHA 2022)

Confirm myocardial involvement (myopericarditis); fibrosis pattern (ACC/AHA 2022)

Most common idiopathic / viral etiology (ACC/AHA 2022)

Dressler / post-pericardiotomy syndrome (ACC/AHA 2022)

SLE / RA / vasculitis / uremic pericarditis (ACC/AHA 2022)

Neoplastic pericardial disease (ACC/AHA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningtamponade_complicating_pericarditis
    Beck triad / pulsus paradoxus / hemodynamic compromise with effusion (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremyopericarditis_with_troponin
    Pericarditis + troponin rise (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretb_or_bacterial_purulent
    Fever + pericardial fluid neutrophilic / AFB + / culture + (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconstrictive_evolution
    Persistent symptoms + pericardial thickening on CMR + RH cath consistent with constriction (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_recurrent
    ≥3 recurrences despite NSAID + colchicine + low-dose steroid (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateautoimmune_pericarditis
    SLE / RA / vasculitis + pericarditis (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pericarditis — NSAID + colchicine + tapered IL-1 escalation (2025 ESC IMPS)
axis: pericarditis_anti_inflammatorystep 1 - Step 1 — First episode (acute pericarditis)
Selected step "Step 1 — First episode (acute pericarditis)" — First-episode acute pericarditis (≥2 ESC criteria)
  • ibuprofen
    first line
    NSAID
    600–800 mg PO TID with food • PO • TID
    triggers: no_uremia, no_GI_bleed_history, no_AC_use
    Tapered: 600 TID × 1–2 wk → 400 TID × 1 wk → 200 TID × 1 wk (ACC/AHA 2022)
    rxcui 5640
  • aspirin
    first line
    NSAID_antiplatelet
    750–1000 mg PO q8h with PPI • PO • q8h
    triggers: post_MI_Dressler, on_AC
    Preferred in post-MI; tapered 1000 TID × 1–2 wk → 500 TID (ACC/AHA 2022)
    rxcui 1191
  • colchicine
    first line
    tubulin_inhibitor
    0.5 mg BID (0.5 mg daily if <70 kg or eGFR <60) • PO • BID
    triggers: acute_pericarditis_first_episode
    COPE / ICAP — Class IA, reduces recurrence; ×3 mo
    rxcui 2683
  • pantoprazole
    add on
    PPI
    40 mg • PO • once daily
    triggers: NSAID_use
    GI protection during NSAID course (ACC/AHA 2022)
    rxcui 40790

outpatient playbook — drug actions (6)

  1. 1. ibuprofen + colchicine
    Ibuprofen 600–800 mg TID + colchicine 0.5 mg BID × 3 mo • PO • TID + BID
    trigger: First episode (ACC/AHA 2022)
    COPE / ICAP Class IA
  2. 2. aspirin + colchicine in post-MI
    Aspirin 750–1000 mg q8h + colchicine 0.5 mg BID • PO • q8h + BID
    trigger: Dressler / post-PCI / on AC (ACC/AHA 2022)
    Avoid NSAID (ACC/AHA 2022)
  3. 3. extend colchicine 6 months in recurrent
    0.5 mg BID × 6 mo • PO • BID
    trigger: Recurrence (ACC/AHA 2022)
    CORP-2 (ACC/AHA 2022)
  4. 4. low-dose prednisone
    0.2–0.5 mg/kg/d, slow taper over 3+ months • PO • daily
    trigger: NSAID-contraindicated / refractory / autoimmune (ACC/AHA 2022)
    Avoid high-dose to minimize relapse (ACC/AHA 2022)
  5. 5. rilonacept or anakinra
    Rilonacept 320 mg SC load → 160 mg weekly OR anakinra 100 mg SC daily • SC • weekly / daily
    trigger: Refractory recurrent / steroid-dependent (ACC/AHA 2022)
    RHAPSODY / AIRTRIP (ACC/AHA 2022)
  6. 6. GI protection PPI
    Pantoprazole 40 mg daily • PO • daily
    trigger: NSAID + age >65 or GI history (ACC/AHA 2022)
    PUD prevention (ACC/AHA 2022)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pleuritic / positional chest pain (ACC/AHA 2022); Pericardial friction rub on auscultation (ACC/AHA 2022); ECG: diffuse ST elevation + PR depression (ACC/AHA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pericarditis (acute / recurrent / IMPS)** (cardio.pericarditis.core.v1).
Phenotype framing: Pericarditis vs myopericarditis vs constrictive vs effusive-constrictive; etiology classification (ACC/AHA 2022)
Scope: Acute (<4–6 wk), incessant (4–12 wk), recurrent (≥1 month-free interval), chronic; IMPS framework (ACC/AHA 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pericarditis — NSAID + colchicine + tapered IL-1 escalation (2025 ESC IMPS)** — step "Step 1 — First episode (acute pericarditis)".
1. ibuprofen 600–800 mg PO TID with food PO TID (NSAID, first line) — Tapered: 600 TID × 1–2 wk → 400 TID × 1 wk → 200 TID × 1 wk (ACC/AHA 2022)
2. aspirin 750–1000 mg PO q8h with PPI PO q8h (NSAID_antiplatelet, first line) — Preferred in post-MI; tapered 1000 TID × 1–2 wk → 500 TID (ACC/AHA 2022)
3. colchicine 0.5 mg BID (0.5 mg daily if <70 kg or eGFR <60) PO BID (tubulin_inhibitor, first line) — COPE / ICAP — Class IA, reduces recurrence; ×3 mo
4. pantoprazole 40 mg PO once daily (PPI, add on) — GI protection during NSAID course (ACC/AHA 2022)

Setting playbook (outpatient) — Manage acute or recurrent pericarditis with NSAID + colchicine, escalate to IL-1 if refractory, monitor CRP, restrict activity, screen for myopericarditis (ACC/AHA 2022)
5. ibuprofen + colchicine Ibuprofen 600–800 mg TID + colchicine 0.5 mg BID × 3 mo PO TID + BID — First episode (ACC/AHA 2022) (COPE / ICAP Class IA)
6. aspirin + colchicine in post-MI Aspirin 750–1000 mg q8h + colchicine 0.5 mg BID PO q8h + BID — Dressler / post-PCI / on AC (ACC/AHA 2022) (Avoid NSAID (ACC/AHA 2022))
7. extend colchicine 6 months in recurrent 0.5 mg BID × 6 mo PO BID — Recurrence (ACC/AHA 2022) (CORP-2 (ACC/AHA 2022))
8. low-dose prednisone 0.2–0.5 mg/kg/d, slow taper over 3+ months PO daily — NSAID-contraindicated / refractory / autoimmune (ACC/AHA 2022) (Avoid high-dose to minimize relapse (ACC/AHA 2022))
9. rilonacept or anakinra Rilonacept 320 mg SC load → 160 mg weekly OR anakinra 100 mg SC daily SC weekly / daily — Refractory recurrent / steroid-dependent (ACC/AHA 2022) (RHAPSODY / AIRTRIP (ACC/AHA 2022))
10. GI protection PPI Pantoprazole 40 mg daily PO daily — NSAID + age >65 or GI history (ACC/AHA 2022) (PUD prevention (ACC/AHA 2022))

Non-pharmacologic actions:
- Activity restriction — no competitive sports until inflammation resolves (≥3 mo for athletes) (ACC/AHA 2022)
- CRP-driven taper completion (ACC/AHA 2022)
- Cardiology referral if recurrent or constrictive evolution (ACC/AHA 2022)
- Etiology workup if atypical (ACC/AHA 2022)

AVOID / contraindication checks:
- NSAID_AVOID_uremic_or_post_MI_acute (ACC/AHA 2022)
- Colchicine_renal_dose_eGFR<60_or_lt_70kg (ACC/AHA 2022)
- Colchicine_drug_drug_macrolide_statin_CYP3A4 (ACC/AHA 2022)
- Steroid_high_dose_AVOID_relapse_risk (ACC/AHA 2022)
- IL_1_blocker_screen_active_infection (ACC/AHA 2022)

Monitoring

Regimen monitoring:
- CRP weekly until normal (ACC/AHA 2022)
- symptom diary
- colchicine GI renal LFT (ACC/AHA 2022)
- ECG + echo at each visit (ACC/AHA 2022)
- CMR for myopericarditis evaluation (ACC/AHA 2022)
- activity restriction 3-6 months (ACC/AHA 2022)

Setting (outpatient) monitoring:
- CRP weekly until normal (ACC/AHA 2022)
- Symptom diary (ACC/AHA 2022)
- Echo at 1 month and per recurrence (ACC/AHA 2022)
- CMR if myopericarditis (ACC/AHA 2022)

Follow-up plan: Recurrence prevention; cardiology referral for recurrent or constrictive evaluation (ACC/AHA 2022)
- Close-out criterion: follow-up scheduled

Monitoring phase: CRP weekly until normal; symptom diary; monitor colchicine GI / renal; activity restriction (no competitive sports until inflammation resolves) (ACC/AHA 2022)

Disposition

Current setting: outpatient — Manage acute or recurrent pericarditis with NSAID + colchicine, escalate to IL-1 if refractory, monitor CRP, restrict activity, screen for myopericarditis (ACC/AHA 2022)

Disposition criteria:
- Outpatient if low-risk (no fever, no large effusion, no troponin rise, NSAID-responsive) (ACC/AHA 2022)
- Admit if high-risk features (per ESC)

Escalation triggers (move to higher acuity):
- Tamponade physiology → ED (ACC/AHA 2022)
- Recurrence on max therapy → IL-1 blockade (ACC/AHA 2022)
- Constrictive features → pericardiectomy referral (ACC/AHA 2022)
- High fever >38 + WBC + bacterial features → admit for purulent / TB workup (ACC/AHA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Beck triad / pulsus paradoxus / hemodynamic compromise with effusion (ACC/AHA 2022)
- [SEVERE] Pericarditis + troponin rise (ACC/AHA 2022)
- [SEVERE] Fever + pericardial fluid neutrophilic / AFB + / culture + (ACC/AHA 2022)

Citations

- 2025 ESC Myocarditis/Pericarditis Guideline (IMPS) + 2025 ACC Expert Consensus [PMID:16186437](https://pubmed.ncbi.nlm.nih.gov/16186437/)
- Cited evidence (PMID 23992557) [PMID:23992557](https://pubmed.ncbi.nlm.nih.gov/23992557/)
- Cited evidence (PMID 21873705) [PMID:21873705](https://pubmed.ncbi.nlm.nih.gov/21873705/)
- Cited evidence (PMID 24694983) [PMID:24694983](https://pubmed.ncbi.nlm.nih.gov/24694983/)
- Cited evidence (PMID 33200890) [PMID:33200890](https://pubmed.ncbi.nlm.nih.gov/33200890/)

Last reconciled with current guidelines: 2026-05-10.
References