Pericarditis: Complete Clinical Overview

1. Definition

2. Types / Classification

By Duration

By Etiology

• Viral (most common): Coxsackievirus A/B, echovirus, adenovirus, Epstein-Barr virus, influenza, cytomegalovirus — a specific virus is isolated in only 15–30% of cases
• Bacterial: Pneumococcus, S. aureus, meningococcus, Haemophilus influenzae (~30% of infectious cases in children); tuberculosis (leading cause in developing countries and immunocompromised patients)
• Fungal and parasitic (rare)

• Post-cardiac injury syndromes: Post-MI (Dressler syndrome — occurs 1–8 weeks post-MI due to autoimmune response to injured myocardium), post-pericardiotomy, post-radiation, post-trauma
• Systemic inflammatory diseases: SLE (pericarditis in 40–80% at autopsy), Rheumatoid arthritis, Systemic sclerosis, Rheumatic fever, Sarcoidosis, Amyloidosis
• Uremia — most common systemic disorder associated with pericarditis
• Malignancy: Metastatic tumors (lung, breast, lymphoma, GI), primary cardiac tumors
• Drugs: Hydralazine, procainamide, isoniazid, certain chemotherapy agents
• Aortic dissection

3. Pathophysiology

1. An inciting agent (virus, bacteria, autoantigen, uremic toxin, trauma) triggers an inflammatory cascade within the pericardium
2. Granulocytic and lymphocytic infiltration occurs, releasing inflammatory mediators
3. The pericardial surfaces become edematous and inflamed
4. Exudate forms — type depends on etiology:
   • Fibrinous (viral, uremic): irregular, shaggy "bread-and-butter" appearance
   • Fibrinopurulent/suppurative (bacterial): pus accumulation
   • Caseating (tuberculous)
   • Serosanguineous/bloody (malignancy)
5. Pericardial effusion may develop if exudate accumulates in the pericardial space
6. Rapid or large accumulation of fluid → cardiac tamponade (compression of myocardium → ↓ stroke volume → ↓ cardiac output → shock)
7. Healing with fibrosis → constrictive pericarditis (dense scar encases the heart, impairing diastolic filling)

Acute suppurative (purulent) pericarditis caused by extension from pneumonia — Robbins & Kumar Basic Pathology

4. Clinical Manifestations

Symptoms

• Chest pain — the hallmark symptom; sharp, pleuritic in quality
  • Worsened by: supine position, deep inspiration, swallowing, coughing
  • Relieved by: sitting upright and leaning forward (classic position)
  • Retrosternal location; may radiate to the trapezius ridge or back (highly specific for pericarditis), or present as isolated shoulder pain
• Fever and myalgias (common preceding history)
• Dyspnea — may have pleuritic component
• Fatigue, malaise

Signs

• Pericardial friction rub — pathognomonic physical finding
  • Caused by friction between inflamed visceral and parietal pericardium
  • Best heard: lower left sternal border, patient leaning forward in full expiration
  • Has up to 3 components: ventricular systole, early ventricular diastole, atrial systole ("to-and-fro" or "creaking leather" quality)
  • Intermittent and migratory — may disappear as effusion develops
• Tachycardia — may be the only finding in some patients
• If effusion develops: muffled heart sounds, distended neck veins, pulsus paradoxus

Signs of Complications

• Cardiac tamponade: Beck's triad — hypotension + distended neck veins + muffled heart sounds; pulsus paradoxus > 10 mmHg, tachycardia, tachypnea, hepatomegaly, lower extremity edema
• Constrictive pericarditis: right-sided heart failure (dyspnea, fatigue, weight gain, hepatomegaly, marked lower extremity edema, ascites), pericardial knock in early diastole

5. Diagnostic Criteria (Definitive Diagnosis)

ESC 2015 Diagnostic Criteria for Acute Pericarditis

6. Diagnostic Investigations

ECG — Most Reliable Initial Tool

ECG showing diffuse concave ST elevation with PR depression — classic acute pericarditis pattern

Laboratory Studies

Imaging

• Echocardiography (TTE/POCUS) — First-line imaging; detects pericardial effusion in up to 60% of patients; normal echo does NOT exclude pericarditis; assesses for tamponade
• Chest X-ray — May show enlarged cardiac silhouette ("water-bottle heart") with large effusion; may be normal; pericardial calcification suggests constrictive pericarditis
• Cardiac MRI — Gold standard for assessing pericardial inflammation: pericardial delayed gadolinium hyperenhancement confirms active inflammation; identifies myocarditis component; superior for constrictive vs. restrictive differentiation
• CT scan — Pericardial thickening (> 4 mm), calcification; useful for constrictive pericarditis

Pericardiocentesis / Pericardial Fluid Analysis

• Indicated when: tamponade, large effusion, suspicion of bacterial/tuberculous pericarditis, malignancy
• Fluid analysis: cell count, glucose, protein, LDH, culture, cytology, AFB stain, ADA (adenosine deaminase for TB)
• Note: routine fluid analysis is rarely diagnostically useful unless infection is specifically suspected; immune complexes, ANA, complement levels may be checked in autoimmune cases

High-Risk Features Requiring Hospitalization (ESC)

• Fever > 38°C
• Subacute onset
• Large effusion or tamponade
• Failure to respond to NSAIDs within 7 days
• Immunosuppression, trauma, anticoagulant therapy, myopericarditis

7. Management

Acute Idiopathic/Viral Pericarditis

1. NSAIDs + Colchicine (Class I recommendation, ESC 2015)
   • Ibuprofen 600 mg QID × 10 days, OR Aspirin 650 mg TID × 10 days (preferred post-MI), OR Indomethacin 25 mg TID
   • Colchicine: 0.5 mg once daily (weight < 70 kg) or 0.5–0.6 mg twice daily (weight ≥ 70 kg) for 3–6 months
   • Adding colchicine reduces persistent/recurrent pericarditis by ~50% (COPE and ICAP randomized trials)
2. Activity restriction: athletes should avoid competitive sports until complete resolution of symptoms and normalization of CRP, ECG, and echocardiogram

• Low- to moderate-dose corticosteroids: Prednisone 0.2–0.5 mg/kg/day (lower dose has fewer recurrences and complications than 1.0 mg/kg/day)
• Steroids should be used sparingly — they increase recurrence risk and impair pericarditis resolution
• Post-MI: defer steroids ≥ 4 weeks (impair infarct healing, risk of ventricular aneurysm)
• Avoid heparin in active pericarditis (risk of pericardial hemorrhage)

• IL-1 receptor antagonist: Anakinra (supported by the AIRTRIP randomized trial) — for recurrent idiopathic/autoinflammatory pericarditis
• Network meta-analysis (PMID 39705019, 2025) confirms colchicine + IL-1 antagonists are most effective for recurrent pericarditis
• Pericardiectomy: reserved for medically refractory cases or when constriction develops

Specific Etiologies

8. Prognosis

• Idiopathic/viral pericarditis: Self-limited in 70–90% of cases; excellent prognosis
• Recurrence rate: 15–30% with NSAIDs alone; reduced to ~7–15% with colchicine added
• Constrictive pericarditis: Develops in a minority; pericardiectomy has ~10% mortality
• Bacterial pericarditis: 30% survival with antibiotics alone; ~50% with antibiotics + drainage
• Cardiac tamponade: Life-threatening emergency; prompt pericardiocentesis is curative
• Poor prognostic indicators (require hospitalization):
  • Fever > 38°C
  • Large effusion or tamponade
  • Subacute course
  • Failure of NSAIDs within 1 week
  • Immunosuppression
• Myopericarditis (concurrent myocardial involvement): generally favorable prognosis with appropriate management but requires troponin monitoring and cardiac MRI

9. Health Teachings (Patient Education)

Medications

• Take NSAIDs with food to prevent stomach upset; do not stop abruptly
• Colchicine must be taken for the full 3–6 months even after symptoms resolve — stopping early significantly increases recurrence
• Watch for colchicine side effects: diarrhea, nausea, abdominal cramping — report to provider; dose may be adjusted
• Do not take NSAIDs if you have kidney disease, peptic ulcer, or are pregnant without provider guidance

Activity Restrictions

• Avoid all strenuous physical activity, exercise, and competitive sports until pericarditis is fully resolved (symptoms gone + CRP normal + ECG/echo normalized)
• Rest as much as possible during the acute phase
• For athletes, this restriction can last weeks to months — premature return increases recurrence risk

Warning Signs — When to Return to Emergency Department Immediately

• Sudden worsening chest pain or pressure
• Difficulty breathing
• Rapid or irregular heartbeat
• Lightheadedness, dizziness, or fainting
• Swelling of the legs or abdomen (signs of constrictive pericarditis)
• High fever unresponsive to medication

Follow-up

• Regular follow-up appointments with cardiologist to confirm complete resolution
• Repeat CRP, ECG, and echocardiogram before returning to full activity
• Inform future healthcare providers about the episode of pericarditis (important for surgical planning, anticoagulation decisions)

Lifestyle

• Avoid alcohol during treatment — it can worsen inflammation and interact with medications
• Stay well hydrated, especially with colchicine use
• Reduce stress and ensure adequate rest
• Do not miss dialysis sessions if you are on dialysis (uremic pericarditis)

Understanding Recurrence

• Recurrence occurs in up to 30% of patients — this does NOT mean you did anything wrong
• Completing the full course of colchicine is the single most important step to prevent recurrence
• Report any recurrence of chest pain promptly — early treatment reduces complications

Infectious Precautions

• Most viral pericarditis follows upper respiratory infections; practice good hand hygiene
• Vaccinations (influenza, pneumococcal) reduce risk of viral/bacterial triggers

Summary Table

• ROSEN's Emergency Medicine, 9th ed., Ch. 68
• Robbins & Kumar Basic Pathology, 10th ed., Ch. 9
• Mulholland & Greenfield's Surgery, 7th ed., Ch. on Pericardial Diseases
• Braunwald's Heart Disease, 12th ed.
• Washington Manual of Medical Therapeutics
• ESC 2015 Guidelines on Pericardial Diseases
• Desai D et al., Network Meta-Analysis, Panminerva Med 2025 [PMID: 39705019]
• Klein AL et al., JACC Cardiovasc Imaging 2024 [PMID: 39111992]