Pericarditis is inflammation of the thin sac that surrounds the heart, called the pericardium. While doctors have treated this condition for years, the American College of Cardiology recently released new 2025 guidelines that change how pericarditis should be diagnosed and managed. These updates bring important shifts in both treatment and follow-up, especially for patients who struggle with repeat flare-ups. The CCG represents the first ACC consensus statement ever published in the United States on pericarditis and affirms the standard for managing pericarditis. The guidance was developed by thought leaders from around the world and includes recommendations on disease diagnosis, management, and imaging. The “Concise Clinical Guidance” provides guidance, focused on specific clinical scenarios before more comprehensive evidence and guidelines are available.
Clearer Diagnosis Standards
The new guidelines make the diagnosis of pericarditis more precise. Instead of relying on chest pain alone, doctors now look for chest pain plus at least one other sign of inflammation. This can be a “rub” sound heard with a stethoscope, changes on an ECG, fluid buildup around the heart, elevated blood markers like CRP, or cardiac imaging that shows swelling. The guidance also strengthens the way doctors classify the condition: acute (less than 6 weeks), incessant (lasting beyond 6 weeks without a break), recurrent (a new flare after at least 4–6 weeks without symptoms), or chronic (lasting more than 3 months).
Updated Role of Testing
Echocardiograms, ECGs, and blood work remain the starting point for most patients. But the new guidelines highlight the growing role of cardiac MRI (CMR), which can directly show inflammation and help determine how active the disease is. This is particularly helpful for patients with recurrent or confusing cases. CT scans, on the other hand, are still not recommended as a routine first test.
First-Line Treatment: Stronger Endorsement of Colchicine
One of the clearest updates in the 2025 guidance is the strong recommendation for colchicine as part of first-line therapy. Colchicine, paired with a high-dose NSAID or aspirin, is now considered standard treatment for almost everyone with pericarditis. Colchicine is prescribed for 3 months after a first episode, and for 6–12 months if the condition recurs. The anti-inflammatory drug is started at a high dose and then carefully tapered once pain improves and blood tests settle down. Exercise restriction also remains essential, with patients advised to keep their heart rate below 100 during recovery.
What Happens if First-Line Therapy Fails?
In the past, doctors often turned to steroids like prednisone when colchicine and NSAIDs weren’t enough. The 2025 guidance still allows this, but stresses that steroids should be used carefully, at the lowest effective dose, and tapered very slowly. This is because steroids can trigger flare-ups when stopped too quickly and carry risks such as weight gain, high blood sugar, and bone loss.
The Biggest Change: Anti-IL-1 Medicines
The most important update in the 2025 guidelines is the recommendation for anti-IL-1 medicines—rilonacept and anakinra—as a preferred option for patients with recurrent or inflammatory pericarditis. These medicines work by directly blocking the inflammation that drives the disease, often leading to fast pain relief and fewer recurrences. In fact, the guidance now places them ahead of steroids for many patients with repeat flare-ups. Treatment usually lasts for at least a year, with other medications slowly tapered off during that time. Patients must be screened for infections before starting these therapies, but for many, they offer a safer and more effective path than long-term steroid use.
Surgery: Reserved for Severe Cases
While most patients respond to medicines, the guidelines confirm that surgery may be necessary in rare cases. If fluid keeps building up or causes dangerous pressure on the heart (tamponade), doctors may need to drain it. For severe, long-lasting cases where the pericardium becomes stiff and restrictive, a surgery called pericardiectomy—removing the sac—may be considered at specialized centers.
Special Cases and Preventive Care
The new guidance also touches on patients who develop pericarditis after heart surgery or those with autoimmune conditions. In these cases, colchicine may help prevent flare-ups, and treatment of the underlying disease often improves pericarditis itself.
Importance of Specialized Follow-Up
Finally, the guidelines highlight the growing role of Pericardial Disease Centers, where patients can see a team of specialists, get quick imaging, and have their treatment tailored over time. Regular follow-up—every 3 months while active, and every 6–12 months when stable—reduces the risk of flare-ups and helps patients recover more fully.
Takeaway: A New Era in Pericarditis Care
The 2025 pericarditis guidelines mark a big step forward. Colchicine is now firmly established as a first-line treatment, cardiac MRI has an expanded role in diagnosis, and anti-IL-1 medicines are recognized as a major breakthrough for patients with recurring or hard-to-treat cases. Surgery remains a last resort, but long-term care and specialized centers are now seen as vital to better outcomes. For patients, this means more precise diagnosis, better treatment options, and a clearer path to recovery.
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