Cardiology > Acute Pericarditis 

Background

Acute pericarditis is an inflammation of the pericardial sac that typically presents with sharp, pleuritic chest pain relieved by sitting forward, a pericardial friction rub, and characteristic ECG changes. It is the most common disorder of the pericardium and may be idiopathic, viral, autoimmune, or secondary to systemic or cardiac pathology. 

II) Classification/Types

By Duration: 

• • Acute: <4–6 weeks 

• • Incessant: >4–6 weeks, <3 months without remission 

• • Recurrent: Return of symptoms after symptom-free interval of ≥4–6 weeks 

• • Chronic: >3 months duration 

By Etiology: 

• • Idiopathic/viral (most common) 

• • Autoimmune/immune-mediated (e.g., SLE) 

• • Neoplastic 

• • Tuberculous 

• • Post-myocardial infarction (Dressler syndrome) 

III) Pathophysiology 

Acute pericarditis results from inflammation of the pericardial layers. This leads to increased vascular permeability and the accumulation of inflammatory mediators, causing pain and, sometimes, pericardial effusion. In some cases, autoimmune mechanisms (e.g., molecular mimicry) contribute, particularly in recurrent or Dressler-related pericarditis. 

IV) Epidemiology

• • Age: Common in adults aged 20–50 years 

• • Sex: Slight male predominance 

• • Geography: Viral etiologies more common in developed nations; tuberculosis is a leading cause in developing countries 

• • Incidence: Accounts for ~0.1% of hospitalized patients and 5% of ER visits for chest pain 

Etiology

I) Causes

• • Idiopathic/viral: Coxsackievirus, echovirus, influenza, HIV 

• • Bacterial: Tuberculosis, purulent pericarditis (rare) 

• • Post-infarction: Dressler syndrome 

• • Post-surgical: Postpericardiotomy syndrome 

• • Autoimmune: SLE, RA, scleroderma 

• • Uremic: ESRD with inadequate dialysis 

• • Neoplastic: Lung or breast cancer, lymphoma, leukemia 

• • Radiation-induced 

• • Drug-induced: Isoniazid, hydralazine, procainamide 

II) Risk Factors

• • Recent viral infection 

• • Autoimmune disease 

• • Recent cardiac surgery or MI 

• • Uremia 

• • Cancer 

• • Immunosuppression 

Clinical Presentation

I) History (Symptoms)

• • Chest pain: Sharp, pleuritic, retrosternal or left-sided; worsens with lying flat, improves with sitting up 

• • Dyspnea: Often positional 

• • Fever: Low-grade or febrile depending on etiology 

• • Fatigue, myalgias: If viral or systemic 

• • Recent viral prodrome or upper respiratory symptoms 

II) Physical Exam (Signs)

Vital Signs: 

• • Fever 

• • Tachycardia 

Cardiac Exam: 

• • Pericardial friction rub: High-pitched, scratching sound best heard at the left lower sternal border with patient leaning forward 

Pulmonary: 

• • Clear unless associated effusion compresses lung bases 

Peripheral: 

• • Usually normal; signs of tamponade (hypotension, JVD) suggest pericardial effusion 

Differential Diagnosis (DDx)

• • Myocardial infarction 

• • Pulmonary embolism 

• • Aortic dissection 

• • Myocarditis 

• • GERD 

• • Musculoskeletal chest pain 

• • Pleuritis 

• • Costochondritis 

Diagnostic Tests

Initial Tests 

ECG: 

• • Diffuse ST-segment elevation (concave) and PR depression 

• • Later stages may show T-wave inversion and normalization 

Chest X-ray: 

• • May show enlarged cardiac silhouette if large effusion present 

• • Usually normal 

Echocardiogram (TTE): 

• • Evaluate for pericardial effusion 

• • Normal LV function 

Inflammatory Markers: 

• • Elevated ESR, CRP 

• • Leukocytosis 

Troponin: 

• • Mildly elevated if myocarditis component (myopericarditis) 

Pericardial fluid analysis (if effusion present): 

• • Exudative, lymphocytic or neutrophilic depending on cause 

• • Send for Gram stain, AFB, cytology 

Advanced Testing (if indicated): 

• • ANA, RF, TB testing 

• • HIV 

• • TSH 

• • Cardiac MRI: Detects pericardial inflammation or thickening 

Treatment

I) Medical Management

First-Line: 

• • NSAIDs: Ibuprofen 600–800 mg TID or Aspirin 650–1000 mg TID for 1–2 weeks 

• • Colchicine: 0.5–0.6 mg BID (or once daily if <70 kg) for 3 months; reduces recurrence 

Adjunctive: 

• • Gastroprotection: PPI if prolonged NSAID use 

Second-Line (if refractory or contraindicated to NSAIDs/colchicine): 

• • Corticosteroids: Prednisone 0.25–0.5 mg/kg/day tapered over weeks 

• • Use caution: increases recurrence risk 

Treatment of underlying cause: 

• • Antibiotics for bacterial pericarditis 

• • Antitubercular therapy for TB 

• • Dialysis for uremic pericarditis 

• • Immunosuppressive therapy for autoimmune pericarditis 

II) Interventional/Surgical

• • Pericardiocentesis: For cardiac tamponade or diagnostic purposes 

• • Pericardial window: In recurrent or loculated effusions 

• • Pericardiectomy: Rare, for constrictive pericarditis or chronic recalcitrant cases 

Patient Education, Screening, Vaccines

Education: 

• • Explain inflammatory nature of disease 

• • Importance of medication adherence and tapering 

• • Avoid exercise until symptom and marker resolution 

Lifestyle: 

• • Rest during acute phase 

• • Avoid alcohol and NSAIDs overuse 

Vaccinations: 

• • Influenza and pneumococcal 

• • COVID-19 vaccine 

Consults/Referrals

• • Cardiology: For diagnostic uncertainty, effusion, or high-risk features 

• • Infectious Disease: If TB or bacterial infection suspected 

• • Rheumatology: If autoimmune pericarditis suspected 

• • Thoracic Surgery: For pericardial window or pericardiectomy in refractory cases 

Follow-Up

• • Reassess symptoms and inflammatory markers weekly 

• • Echocardiogram: At diagnosis and if effusion suspected or recurs 

• • Monitor for recurrence: Occurs in 15–30% of idiopathic cases 

• • Colchicine continuation for 3 months (first episode), up to 6 months for recurrences 

• • Regular outpatient follow-up until CRP and symptoms normalize