Pericarditis

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Pericarditis

Definition & Epidemiology

Pericarditis is inflammation of the pericardium caused by granulocytic and lymphocytic infiltration. It accounts for approximately 5% of all non-ischemic chest pain in the emergency setting. In Western countries, 80–90% of cases are labeled idiopathic, though most are presumed viral. Tuberculosis is a leading cause in developing countries.

— Rosen's Emergency Medicine, p. 1121

Etiology

Category	Examples
Infectious	Viral (coxsackievirus, echovirus, adenovirus, EBV, influenza), bacterial (pneumococcus, S. aureus, meningococcus, H. influenzae), fungal, parasitic
Post-injury / Iatrogenic	Post-MI (Dressler syndrome), post-pericardiotomy, blunt/penetrating trauma, radiation, cardiac procedures
Systemic / Autoimmune	SLE, RA, systemic sclerosis, sarcoidosis, amyloidosis
Metabolic	Uremia
Neoplastic	Metastatic tumors, primary tumors
Drug-induced	Various agents (see recent 2026 systematic review, PMID 41276190)

A specific viral agent is recovered in only 20–30% of viral cases; no cause is established in up to 55% of patients in comprehensive studies.

Pathophysiology

The pericardium consists of parietal and visceral layers (each 1–2 mm), with a 15–35 mL ultrafiltrate normally present in the pericardial space. Its functions include maintaining cardiac position, preventing infection spread, and maintaining normal pressure-volume relationships. Inflammation leads to increased antibodies in pericardial fluid; recent research distinguishes autoinflammatory vs. autoimmune pericarditis.

Clinical Features

Symptoms

Chest pain: sharp, pleuritic, retrosternal — the cardinal symptom
- Worsened by lying supine, deep inspiration, swallowing
- Relieved by sitting forward (orthopnea characteristic)
- Can radiate to trapezius muscles, back, or present as isolated shoulder pain
Fever, myalgias, dyspnea (may have pleuritic component)

Signs

Pericardial friction rub — pathognomonic
- Best heard: lower left sternal border, diaphragm of stethoscope, patient leaning forward in full expiration
- Has up to 3 components (ventricular systole, early diastolic filling, atrial systole)
- Tends to be intermittent and migratory

Diagnosis

No single test is diagnostic. The diagnosis requires ≥2 of 4 criteria:

Typical chest pain
Pericardial friction rub
ECG changes
New/worsening pericardial effusion

Classic pain + ECG pattern seen in only ~two-thirds of patients.

ECG Changes (4 Stages)

Stage	Timing	Findings
1	Hours–days	Diffuse concave (saddle-shaped) ST elevation, reciprocal ST depression in aVR, PR depression in most leads, PR elevation in aVR
2	Days	ST and PR segments normalize
3	Days–weeks	T-wave flattening → deep, symmetrical T-wave inversions
4	Weeks	ECG returns to normal (T-wave inversions may persist)

Key ECG distinguishing features from STEMI:

ST elevation is concave (not convex)
Diffuse distribution (not single coronary territory)
No simultaneous T-wave inversion with ST elevation
No Q waves develop
PR depression is highly specific for pericarditis (Spodick's sign = down-sloping TP segments)

12-lead ECG showing classic acute pericarditis: diffuse saddle-shaped ST elevation, PR depression in II and lateral leads, reciprocal changes in aVR

Classic 12-lead ECG of acute pericarditis: diffuse concave ST elevation, PR depression (most visible in II), PR elevation in aVR, and Spodick's sign. Note the non-territorial distribution distinguishing it from STEMI.

Other Investigations

Echocardiography: effusion in up to 60% (POCUS); normal echo does not exclude pericarditis
CRP: elevated in inflammation; useful for monitoring treatment response
CBC, ESR: not sensitive or specific
Troponin: elevated in ~35% if concurrent myopericarditis
Cardiac MRI: pericardial delayed hyperenhancement confirms ongoing inflammation; defines extent of involvement
Pericardial fluid analysis: rarely useful unless infective pericarditis is suspected

Management

Acute Pericarditis

First-line (NSAIDs ± Colchicine):

Ibuprofen 600 mg QID × 10 days or
Indomethacin 25 mg TID or
Aspirin 650 mg TID × 10 days
If initial NSAID fails within 1 week, switch NSAID class (e.g., naproxen 250 mg BID × 7 days)

Colchicine (add to NSAIDs):

Reduces recurrence rate by ~50% (COPE trial)
Weight ≥70 kg: 0.5–0.6 mg BID; weight <70 kg: 0.5 mg once daily
Duration: 3–6 months
Caution: renal failure, pregnancy
Start in the ED for best outcomes

Second-line (Corticosteroids):

Reserved for: failure of NSAIDs/aspirin, contraindication to NSAIDs, anticoagulant use
Low-to-moderate dose preferred: prednisone 0.2–0.5 mg/kg/day (lower recurrence than 1 mg/kg/day)

Refractory / Recurrent Pericarditis:

Anakinra (IL-1β receptor antagonist) — promising in colchicine-refractory or steroid-dependent cases
Azathioprine, IVIG — limited evidence
Pericardiectomy — last resort

Disposition

Indication for Hospitalization	Details
Hemodynamic abnormality	Tamponade physiology
Temperature >38°C / 100.4°F	High-risk feature
Large effusion	Risk of tamponade
Failure of first-round treatment	—
Diagnostic uncertainty with ACS	Rule out STEMI

Activity restriction: Athletes should avoid competition until symptom-free (expert consensus).

Special Populations

Autoimmune / Connective Tissue Disease

SLE: pericarditis usually accompanies disease flare; typically mild; cardiac tamponade rare (1–2%)
RA: clinically significant pericarditis in only 1–2%; can progress to constrictive pericarditis over months; predominantly seropositive males
Systemic sclerosis: pericardial disease common, especially in diffuse SSc; usually small effusions, rarely hemodynamically significant

Uremic Pericarditis

Occurs in ESRD (hemodialysis > peritoneal dialysis); one of the most common causes of cardiac tamponade
ECG often normal (unlike typical pericarditis)
Treatment: intensive dialysis, indomethacin 25 mg TID; steroids (prednisone 50 mg QD or intra-pericardial) for non-responders
Can progress to constrictive pericarditis → pericardial window or pericardiectomy

Pediatric Pericarditis

Usually self-limited and benign
Common causes: viral, bacterial (~30%; pneumococcus, S. aureus, meningococcus, H. influenzae), ARF, SLE, uremia, post-pericardiotomy syndrome, leukemia/lymphoma, TB

Prognosis & Complications

Outcome	Frequency
Complete recovery within 1 week	~60%
Complete recovery within 3 weeks	~80%
Recurrence	Up to 30%
Conversion to constrictive pericarditis	Higher in nonviral/nonidiopathic forms

Risk factors for recurrence: fever, pericardial effusion, subacute course, failure of initial NSAID therapy.

Ventricular dysrhythmias in pericarditis should prompt suspicion of concurrent myocarditis, a different cardiac disease, or misdiagnosis.

Recent Evidence

A 2026 systematic review (PMID 41276190, Int J Cardiol) reviewed all published cases of drug-induced pericarditis, highlighting this as an under-recognized cause to consider in the diagnostic workup.

Sources: Rosen's Emergency Medicine, 10e | Braunwald's Heart Disease, 12e | Fuster and Hurst's The Heart, 15e | The Washington Manual of Medical Therapeutics

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