2025 ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis

Authors, Journal, Affiliations, Type, DOI

• Wang TKM, Klein AL, Cremer PC, Imazio M, Kohnstamm S, et al. (Writing Committee)
• Journal of the American College of Cardiology (JACC), 2025;86(25):2691–2719
• Multi-institutional; Chair: Tom Kai Ming Wang; Vice Chair: Allan L. Klein
• Type: ACC Expert Consensus Statement (Concise Clinical Guidance)
• DOI: https://doi.org/10.1016/j.jacc.2025.05.023

Overview

This 2025 ACC Concise Clinical Guidance updates diagnostic and management strategies for acute and recurrent pericarditis using a multimodality imaging-guided approach. Novel diagnostic criteria are proposed — pleuritic chest pain (mandatory) plus ≥1 of 5 additional criteria — replacing the prior ESC 2015 framework. A major paradigm shift positions anti-IL-1 agents as the preferred second-line therapy over corticosteroids for recurrent/incessant inflammatory pericarditis. CMR is elevated to a central role for risk stratification, phenotyping, and monitoring with a new LGE grading scale. Pericardial Diseases Centers (PDC) are endorsed as multidisciplinary referral hubs.

Keywords

Pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, cardiac magnetic resonance, interleukin-1, colchicine, NSAIDs, multimodality imaging, recurrent pericarditis

Key Takeaways

Anatomy and Physiology

• Pericardium = fibrous parietal layer + elastic visceral layer; normally contains 20–50 mL serum ultrafiltrate
• Functions: mechanical (limits cardiac distension, pressure-volume relationships), membranous (lubrication, barrier), metabolic (vasomotor, fibrinolytic), ligamentous (limits displacement)
• Absence of pericardium (post-pericardiectomy or congenital) does not significantly alter cardiac function

Epidemiology

• Pericarditis accounts for 0.1% of hospital admissions and 5% of ED chest pain evaluations
• More common in men aged 16–65 years; incidence declines ~51% per 10-year increase in age
• Recurrent pericarditis is more common in women
• Idiopathic/viral most common in high-income countries; tuberculosis predominates in low-income countries
• ~15% of pericarditis cases have concomitant myocarditis (peri-myocarditis or myo-pericarditis)

Novel Diagnostic Criteria (ACC 2025)

• Mandatory criterion: Pleuritic chest pain (sharp, relieved by sitting up/leaning forward) or clinical equivalent
• Additional criteria (0 = unlikely, 1 = possible, 2+ = definite diagnosis):
  • Pericardial friction rub (present in <1/3 of cases)
  • ECG changes: diffuse ST-segment elevation and/or PR-segment depression (up to 60%)
  • Elevated inflammatory biomarkers: CRP, sedimentation rate
  • New or worsening pericardial effusion on cardiac imaging (up to 60%)
  • Pericardial inflammation on CMR (LGE/edema) or CT
• Differs from ESC 2015 criteria: chest pain now mandatory; CMR incorporated as equal criterion; definite/possible/unlikely categorization introduced

Clinical Classification by Duration

• Acute pericarditis: full symptom resolution within 4 weeks
• Incessant pericarditis: symptoms 4–6 weeks to <3 months before resolution
• Chronic pericarditis: symptoms >3 months
• Recurrent pericarditis: relapse following ≥4–6 week symptom-free interval after completing medical therapy
• Recurrence rates: 15–30% after first episode; up to 50% after a first recurrence

Phenotypes

• Inflammatory phenotype (80–90%): elevated CRP, fever, neutrophilic leukocytosis, effusions — favors anti-IL-1 agents
• Non-inflammatory phenotype (10–20%): near-normal CRP, often autoimmune-mediated — favors corticosteroids

Risk Factors for Poor Prognosis / Recurrence

• Failure to respond to NSAIDs
• Early use of corticosteroids (increases recurrence risk)
• High CRP
• Severe pericardial LGE on CMR
• Large pericardial effusion with tamponade physiology
• Concomitant myocarditis
• High fever, subacute course

Multimodality Imaging

Transthoracic Echocardiography (TTE) — First-line

• Assesses: pericardial effusion (presence, size, hemodynamic impact), tamponade physiology, constrictive physiology, myocardial involvement (wall motion, systolic function)
• Main limitation: cannot tissue-characterize pericardial inflammation
• Pericardial effusion sizing (end-diastolic greatest diameter perpendicular to epicardium):
  • Trivial: <1.0 cm (not visualized throughout cardiac cycle)
  • Small: <1.0 cm
  • Moderate: 1.0–1.9 cm
  • Large: 2.0–2.5 cm
  • Very large: >2.5 cm

Cardiac MRI (CMR) — Second-line, critical for complex/recurrent cases

• Indications: acute complicated, incessant, recurrent, or chronic pericarditis; diagnostic uncertainty; treatment non-responders; suspected constrictive physiology
• Key CMR findings:
  • Pericardial LGE (neovascularization/inflammation) — ideally fat-suppressed PSIR sequence
  • Increased T2-STIR signal (pericardial edema)
  • Pericardial thickening >3 mm (black-blood sequence)
  • LGE+/T2-STIR+: acute/subacute phase or recurrent flare
  • LGE+/T2-STIR−: subacute or chronic phase
  • LGE−/T2-STIR−: resolution or end-stage/calcific phase
• New LGE grading criteria proposed (Figure 7) for pericardial inflammation severity
• LGE lags behind clinical improvement; may not fully resolve in chronic cases

Cardiac CT (CCT) — Selected indications

• Preferred for pericardial calcifications in constrictive pericarditis
• Useful for preoperative planning (pericardiectomy)
• Valuable for differential diagnosis of chest pain (aortic syndromes, PE, CAD)
• NOT recommended for routine pericarditis assessment
• Hounsfield units characterize pericardial fluid: transudate 0–20 HU; exudate 20–50 HU; hemorrhagic >50–60 HU; chylous −60 to −80 HU

Management

First-Line (All patients)

• Dual anti-inflammatory therapy: NSAID/aspirin + colchicine
  • Aspirin 500–1,000 mg TID, tapering weekly after symptom resolution + CRP normalization
  • Ibuprofen 600–800 mg TID (alternative)
  • Colchicine 0.6 mg BID (0.6 mg once daily if <70 kg or renal/hepatic impairment)
  • Duration: 3 months (acute); ≥6 months (recurrent); may be 6–12 months for recurrent
  • Aspirin preferred if patient has concomitant ischemic heart disease
  • PPI co-prescription for gastric protection
• Exercise restriction: ≥1 month, maximum HR <100 bpm, until clinical remission
• For autoimmune pericarditis: treat underlying autoimmune condition first

Corticosteroids — Restricted use

• Prednisone 0.2–0.5 mg/kg/day, maintain until clinical remission, then slow taper over months
• Reserve for: refractory or intolerant to first-line therapy; non-inflammatory phenotype (no elevated CRP)
• Avoid early use in acute pericarditis — increases recurrence risk
• Consider prophylaxis for PCP and osteoporosis if >20 mg/day for ≥1 month

Anti-IL-1 Agents — Paradigm shift (preferred over corticosteroids for inflammatory phenotype)

• Indicated: recurrent/incessant pericarditis with elevated CRP (>1 mg/dL or >10 mg/L) after failure of first-line therapy and/or corticosteroids
• May also be considered in acute pericarditis when other therapies contraindicated/ineffective
• Screen for hepatitis, HIV, tuberculosis before initiation
• Anakinra: 1–2 mg/kg/day (up to 100 mg/day); >12 months; Level of Evidence A
• Rilonacept: 320 mg once, then 160 mg weekly; >12 months; Level of Evidence A (RHAPSODY trial)
• Goflikicept: 80 mg every 2 weeks (not yet available in US); investigational
• Sequential weaning of other anti-inflammatories once established on anti-IL-1 (prednisone → NSAID → colchicine)
• ~50–75% recurrence upon discontinuation; RHAPSODY extension suggests benefit with therapy >18 months
• Optimal treatment duration and stopping method remain uncertain

Salvage Therapies

• Azathioprine: 1 mg/kg/day escalating to 2–3 mg/kg/day; Level of Evidence C
• IVIG: 400–500 mg/kg IV daily × 5 days; Level of Evidence C
• Radical pericardiectomy: last resort at high-volume experienced centers; for medically refractory disease, contraindications to conventional therapy, or desire for pregnancy

Complications of Pericarditis

Pericardial Effusion (Section 4.3.1)

• Defined as >50 mL fluid in pericardial space
• ~50% idiopathic; postviral most common identifiable cause (North America/Western Europe); TB in endemic areas; malignancy important cause
• TTE first-line for sizing, hemodynamic impact, drainage planning
• Inflammatory effusion without tamponade → anti-inflammatory therapy before pericardiocentesis

Cardiac Tamponade (Section 4.3.2)

• Hemodynamic consequences related more to rapidity of fluid accumulation than volume
• Compensatory sinus tachycardia initially; then clinical pulsus paradoxus, hypotension
• Echocardiographic features:
  • Most specific: diastolic RV collapse
  • RA inversion >1/3 cardiac cycle
  • Mitral E-wave respiratory variation >30%; tricuspid >60%
  • IVC >2.1 cm with minimal respiratory variation (sensitive but not specific)
• Pericardiocentesis: indicated for impending or established tamponade; subxiphoid or apical approach in emergency
• Pericardial window: for recurrent effusion/tamponade after prior pericardiocentesis

Constrictive Pericarditis (Section 4.3.3)

• Loss of pericardial elasticity → impaired diastolic filling → HF syndrome with normal EF
• Transient (inflammatory/subacute): predominantly inflammatory, potentially reversible with anti-inflammatory therapy over 3–6 months
• Chronic (advanced): often calcified/fibrotic, irreversible; requires surgical radical pericardiectomy
• Effusive constrictive pericarditis: persistent constrictive physiology after pericardial drainage
• Most common causes outside TB-endemic areas: idiopathic > post-cardiac surgery > mediastinal radiation
• TTE key criteria: annulus reversus (medial > lateral mitral e'), hepatic vein expiratory end-diastolic reversal/forward velocity ≥0.8, respirophasic septal shift, dilated IVC, E-wave dominant LV filling
• CMR: free-breathing cine septal shift; LGE/T2-STIR differentiates transient vs chronic; wall tethering, conical deformity
• Invasive catheterization: if noninvasive data incongruent; systolic area index for LV/RV discordance
• Pericardiectomy: radical resection of entire pericardium (anterior + diaphragmatic + posterior) on CPB; partial pericardiectomy not recommended

Pericarditis in Oncologic Patients (Section 4.3.4)

• Pericardial involvement: direct spread or hematologic/lymphatic dissemination
• Hemorrhagic/complex pericardial effusion increases likelihood of malignant pericardial involvement
• Pericarditis in oncology patients often related to treatment (chemo/immunotherapy/radiation), not direct malignant involvement
• Immunotherapy-associated pericarditis may be subclinical or severe; often with concomitant myocarditis
• Radiation pericarditis/CP: when radiation field includes or is near the pericardium
• Treatment tailored to underlying etiology; improvement of underlying disease generally improves pericardial inflammation
• When pericarditis related to oncologic treatment, drug discontinuation or alternative regimen may be necessary

Pericardial Diseases Center (PDC)

• Multidisciplinary referral center for recurrent, refractory, or complex pericardial disease
• Reduces emergency visits and hospitalizations
• Components: multimodality imaging, rheumatology, infectious diseases, genetics, cardiothoracic surgery, specialty pharmacy
• Follow-up: every 3 months (active); every 6–12 months (stable)
• Indications for referral: recurrent/incessant/chronic pericarditis, suspected constrictive pericarditis, large/complex effusion requiring drainage/window, consideration of biologics or pericardiectomy

Limitations of the Document

• CCG format — not a full systematic guideline; recommendations based on expert consensus where RCT evidence is limited
• Novel diagnostic criteria validated primarily for acute pericarditis; performance in recurrent/incessant pericarditis less established
• Anti-IL-1 agent optimal treatment duration and stopping method unresolved; most data from rilonacept and anakinra; goflikicept not yet US-available
• CMR LGE grading criteria are newly proposed and require prospective validation
• Non-inflammatory phenotype management largely expert-consensus driven (lower evidence)
• Machine learning–based risk scores for recurrence remain investigational

Key Concepts Mentioned

• concepts/Pericarditis — primary subject; novel diagnostic criteria, phenotyping, management algorithm
• concepts/Constrictive-Pericarditis — transient vs chronic forms, imaging, surgical management
• concepts/Pericardial-Effusion — sizing, characterization, imaging, drainage indications
• concepts/Cancer-Therapy-Related-CV-Toxicity — pericarditis in oncology patients

Key Entities Mentioned

• entities/ICD — not directly relevant; mentioned in broader pericardial context
• entities/Atrial-Fibrillation — associated complication of pericarditis/constrictive pericarditis

Wiki Pages Updated

• wiki/sources/pericarditis-acc-2025.md — created
• wiki/concepts/Pericarditis.md — created
• wiki/concepts/Constrictive-Pericarditis.md — created
• wiki/concepts/Pericardial-Effusion.md — created
• wiki/wikiindex.md — updated
• wiki/sourceindex.md — updated
• log.md — updated