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Overview
Pericarditis is the inflammation of the pericardium, which can be acute, subacute, or chronic. It commonly presents with sharp, pleuritic chest pain that improves when sitting up and leaning forward. The most common cause is idiopathic. Diagnosis is based on clinical findings, including pleuritic chest pain, a pericardial friction rub on auscultation, diffuse ST elevation and PR segment depression on ECG, and evidence of pericardial effusion on echocardiography. Management of pericarditis involves treating the underlying cause, reducing inflammation (with NSAIDs as the first line), and monitoring for complications.
Buzzwords Scenario: A patient presents with sharp, pleuritic chest pain that improves when sitting up and leaning forward. Examination reveals a pericardial friction rub, and ECG shows diffuse ST elevation.
Definition
Pericarditis is the inflammation of the pericardium, the double-walled sac surrounding the heart. Classified into acute, subacute, and chronic:
Acute pericarditis: < 6 weeks
Subacute pericarditis: 6 weeks to 6 months
Chronic pericarditis: > 6 months
NOTE: Acute pericarditis is recognized as the most common pathological process involving the pericardium.
EtiologyTable 1: Etiologies of acute pericarditis
Etiological classifications
Cause
Notes
Infectious
Viral
Including Coxsackievirus, echovirus, adenovirus
Bacterial
Tuberculosis
Non-infectious
Idiopathic
Most common in clinical practice
Trauma
Blunt or penetrating chest trauma
Uremic
Seen in patients with renal failure
Malignancy
Primary or secondary tumors of the pericardium
Autoimmune
Post-cardiac injury / Post-Myocardial infarction
Post-pericardiotomy, Post-traumatic • Dressler’s syndrome (2–6 weeks post-MI) • Postinfarction fibrinous pericarditis (1–3 days post MI)
Rheumatological disorders
Lupus, rheumatoid arthritis
Drug induced
Procainamide, hydralazine, phenytoin
NOTE: Most common cause of infectious pericarditis is Coxsackievirus.
Clinical FeaturesTable 2: Symptoms and signs of acute pericarditis
Features
Description
Chest pain
Sharp, pleuritic, positional (better when sitting up and leaning forward)
Pericardial friction rub
Scratchy sound heard over the heart on auscultation, best at the left sternal border
Dyspnea
Shortness of breath due to pain or effusion
Fever, cough, palpitations, fatigue
Nonspecific symptoms
Diagnosis
Suspect pericarditis when a patient presents with pleuritic chest pain, tachypnea, and dyspnea.Pericarditis has 4 principle diagnostic features:
Chest pain: Severe, retrosternal, pleuritic in nature, intensified by lying supine and relieved by sitting up and leaning forward
Pericardial friction rub on auscultation. Found in about 85% of patients at some point of the disease
Characteristic ECG changes (Image 1): Diffuse ST elevations. ST depression in aVR and V1. PR segment depression
Pericardial effusion is initially diagnosed with echocardiography. For confirmation, CT and MRI (gold standard for confirmation) can be used

Figure 1. ECG changes in pericarditis.
Heilman, J. (2016, May 27). Wikimedia Commons: https://commons.wikimedia.org/wiki/File:PericarditisMyocarditis.jpg
Supportive laboratory studies
Elevated cardiac biomarkers (troponin, CK-MB)
Leukocytosis on CBC
Table 3: Other laboratory studies for more specific Etiologies
Laboratory studies
Etiology
Elevated BUN, creatinine, potassium
Uremic pericarditis
Blood cultures (2 sets)
Bacterial pericarditis
ANA, rheumatoid factor
Autoimmune pericarditis
ALERT: Do not forget to rule out all differentials of acute chest pain (e.g., myocardial infarction, myocarditis)
Management
Treat the underlying cause, reduce inflammation, and monitor for complications (Table 3)
Table 3: Management of pericarditis
Treatment
Indication
Notes
NSAIDs
First-line for pain and inflammation
Commonly used drugs include ibuprofen, naproxen, indomethacin.
Colchicine
Prevent recurrence
Given for three months, and often combined with NSAIDs
Corticosteroids
Severe/refractory cases
Prednisone, taper dose gradually
Pericardiocentesis
Large effusion or tamponade
Diagnostic and therapeutic intervention
Antibiotics
Bacterial pericarditis
Tailored based on causative organism
Hemodialysis
Uremic pericarditis
Associated with chronic kidney disease
ALERT: Don’t forget to use gastroprotective drugs (e.g., omeprazole) when administering NSAIDs.
NOTE: In patients with renal or hepatic dysfunction, the use of colchicine is contraindicated.
Complications
Table 4: Complications of pericarditis
Complication
Features
Management
Cardiac tamponade
Beck’s triad • Hypotension • Jugular venous distension • Muffled heart sounds
Emergency pericardiocentesis
Recurrent pericarditis
Similar symptoms of initial episode
Long-term colchicine, monitor regularly
Chronic constrictive pericarditis
Signs of right heart failure, Kussmaul’s sign
Surgical pericardiectomy
NOTE: Do not forget to do echocardiography when pericarditis is suspected to rule out life threatening cardiac tamponade.
Prognosis
The majority of patients with acute pericarditis can be managed as outpatients with careful follow-up. However, hospitalization is advisable under certain conditions:
Suspected specific causes
Tuberculosis
Neoplastic disease
Bacterial infection
Predictors of poor prognosis:
Fever >38°C
Subacute onset
Large pericardial effusion
Reference
Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, & Jameson J (Eds.). (2022). Harrison’s Principles of Internal Medicine, 21st ed. (pp 2022-2023). McGraw-Hill Education.
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