Pericarditis

Table of Contents

  1. Overview
  2. Types and Classification
  3. Causes and Triggers
  4. Symptoms
  5. ECG and Diagnostic Findings
  6. Treatment
  7. Natural and Lifestyle Approaches
  8. Complications and Prognosis
  9. When to Seek Emergency Care
  10. Key Research Papers
  11. Connections
  12. Featured Videos

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1. Overview

Pericarditis is inflammation of the pericardium — the double-layered fibroserous sac surrounding the heart. It is the most common pericardial disease encountered in clinical practice, accounting for approximately 5% of emergency department visits for non-ischemic chest pain. The pericardium normally contains 15–50 mL of serous fluid that lubricates the parietal and visceral pericardial layers as the heart beats.

Inflammation of the pericardium causes characteristic chest pain, a friction rub on auscultation, and distinctive electrocardiographic changes. Pericarditis is most commonly idiopathic (presumed viral) in developed countries, with a self-limited course in the majority of patients. However, recurrence occurs in up to 30% of cases, and a subset of patients develop chronic or constrictive pericarditis requiring invasive treatment.

The ESC 2015 diagnostic criteria define acute pericarditis when at least 2 of the following 4 criteria are present:

  1. Pericarditic chest pain — typically sharp, pleuritic, positional (worse supine, relieved by sitting forward)
  2. Pericardial friction rub — pathognomonic scratching sound heard best at the left sternal border with the patient leaning forward
  3. New widespread ST-segment elevation or PR-segment depression on ECG
  4. New or worsening pericardial effusion on echocardiography or imaging

Elevated inflammatory markers (CRP, ESR, leukocytosis) or evidence of pericardial inflammation on cardiac imaging (CT or CMR) support the diagnosis but are not required. (PMID: 26320112)

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2. Types and Classification

By Duration

By Underlying Cause

By Effusion Status

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3. Causes and Triggers

Infectious Causes

Autoimmune and Inflammatory Triggers

Other Triggers

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4. Symptoms

Cardinal Symptom: Pericarditic Chest Pain

The chest pain of pericarditis has a characteristic pattern that helps distinguish it from other causes of chest pain:

Associated Symptoms

Signs of Cardiac Tamponade (Emergency)

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5. ECG and Diagnostic Findings

Electrocardiography

ECG is central to pericarditis diagnosis and classically evolves through four stages:

The Spodick sign — downsloping TP segment in leads II and V5/V6 — is an early ECG finding with ~29% sensitivity but high specificity for pericarditis.

The PR/ST ratio: In lead II, PR depression >0.8 mm with ST elevation <5 mm favors pericarditis over early repolarization. Low voltage and electrical alternans suggest large pericardial effusion with tamponade physiology. (PMID: 23339841)

Laboratory Findings

Echocardiography

Echo is essential for detecting pericardial effusion, assessing effusion size, and identifying tamponade physiology (RA/RV diastolic collapse, IVC plethora, >25% respiratory variation in mitral/tricuspid inflow velocities). Echo is also important for excluding myocardial wall motion abnormalities that would suggest ACS. (PMID: 24322501)

Cardiac MRI (CMR)

CMR is the gold standard for detecting pericardial inflammation when diagnosis is uncertain. Late gadolinium enhancement (LGE) of the pericardium confirms active inflammation. CMR also assesses myocardial involvement (epicardial LGE in myopericarditis), pericardial thickness (>4 mm suggests constrictive physiology), and pericardial effusion.

CT Chest

CT is useful for pericardial calcification (constrictive pericarditis), effusion characterization, and excluding other causes of chest pain (aortic dissection, pulmonary embolism). Pericardial calcification on CT indicates long-standing pericardial disease and may suggest prior TB or previous purulent pericarditis.

Pericardiocentesis / Pericardial Fluid Analysis

Indicated for large effusions with tamponade physiology, suspected bacterial or TB etiology, or diagnostic uncertainty. Analysis includes: exudate vs. transudate (Light's criteria), glucose, LDH, protein, cell count and differential, cultures (bacterial, TB), cytology (malignant cells), ADA (TB marker >40 U/L suggests TB pericarditis), PCR for viruses and TB. (PMID: 15947410)

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6. Treatment

First-Line Anti-Inflammatory Therapy

The ESC 2015 guidelines recommend aspirin or NSAIDs as first-line therapy for acute pericarditis, with colchicine added as an adjunct: (PMID: 26320112)

Colchicine — Cornerstone of Recurrence Prevention

Colchicine is the key anti-inflammatory adjunct for pericarditis, dramatically reducing recurrence rates. Evidence from landmark trials:

Corticosteroids — Caution

Corticosteroids should NOT be used as first-line therapy for idiopathic/viral pericarditis. Multiple studies demonstrate that corticosteroids increase recurrence rates — likely by suppressing the acute inflammatory response needed for resolution while lowering the threshold for recurrence with steroid tapering. (PMID: 20031835)

Corticosteroids are appropriate for: (1) pericarditis refractory to aspirin/NSAIDs + colchicine; (2) contraindications to aspirin/NSAIDs; (3) specific indications (connective tissue disease-associated, autoimmune, uremic pericarditis). When used: prednisone 0.2–0.5 mg/kg/day for at least 2–4 weeks, then very slow taper over months; never abruptly discontinue; always combined with colchicine.

Anakinra and IL-1 Blockade

For corticosteroid-dependent recurrent pericarditis refractory to colchicine, IL-1 receptor antagonist anakinra (100 mg/day SC) has shown efficacy in inducing remission and enabling corticosteroid tapering. The AIRTRIP trial demonstrated a significant reduction in recurrence (PMID: 27355234). Rilonacept, a long-acting IL-1α/β trap, received FDA approval in 2021 for recurrent pericarditis based on the RHAPSODY trial. (PMID: 34461063)

Activity Restriction

All patients with acute pericarditis should restrict strenuous physical activity for at least 3 months (non-athletes) or until CRP normalizes, symptoms resolve, and ECG normalizes (athletes). Exercise increases the risk of myocardial inflammation spread and arrhythmia in the presence of pericardial/myocardial inflammation.

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7. Natural and Lifestyle Approaches

Rest and Activity Modification

Complete rest during the acute inflammatory phase is essential. The 3-month activity restriction is not merely precautionary — physical exertion directly worsens pericardial inflammation and increases the risk of recurrence and spread to the myocardium. Light walking is acceptable once symptoms begin to resolve; strenuous activity should await CRP normalization.

Anti-Inflammatory Nutrition

Stress Management

Psychological stress modulates immune function and can exacerbate autoimmune and inflammatory conditions. Mind-body practices — meditation, yoga (gentle, avoiding positions that increase cardiac load), and breathwork — may reduce systemic inflammatory burden. Avoid breath-holding exercises and inversions during the acute phase.

Supplements with Anti-Inflammatory Properties

Avoiding Triggers of Recurrence

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8. Complications and Prognosis

Pericardial Effusion

Pericardial effusion develops in up to 60% of pericarditis cases. Most are small and resolve with anti-inflammatory therapy. Large effusions (>20 mm) occurring with acute idiopathic pericarditis are more common in specific etiologies (TB, malignancy, purulent) and are associated with worse outcomes. (PMID: 14665246)

Cardiac Tamponade

Life-threatening hemodynamic collapse from pericardial fluid compressing cardiac chambers and preventing adequate filling. Rate of fluid accumulation matters more than volume — slowly accumulating effusions allow pericardial stretch to accommodate larger volumes than rapidly accumulating effusions. Tamponade requires urgent pericardiocentesis or pericardial window.

Constrictive Pericarditis

The most feared long-term complication of pericarditis — the pericardium becomes fibrosed, thickened (>4 mm), and calcified, causing rigid constriction of cardiac filling. It affects approximately 0.5% of idiopathic/viral pericarditis cases but up to 20–30% of purulent pericarditis and 30–50% of TB pericarditis. Clinically mimics right heart failure: elevated JVP, Kussmaul sign, pericardial knock, ascites, and peripheral edema. Treatment is surgical pericardiectomy (complete stripping of the pericardium). (PMID: 15947410)

Recurrent Pericarditis

The most common complication of acute pericarditis: 20–30% of patients have at least one recurrence. Multiple recurrences occur in 10–15% of patients. Recurrence is associated with prior corticosteroid use, inadequate NSAID/colchicine courses, and absence of colchicine during the first episode. Treatment of recurrence follows the same regimen as first episode, with longer colchicine duration (6 months) and consideration of IL-1 blockade for steroid-dependent cases.

Prognosis

Idiopathic/viral pericarditis has an excellent overall prognosis: nearly all patients recover fully, complications are rare (<1% tamponade, <0.5% constriction), and mortality is very low. Predictors of a complicated course ("high-risk features" per ESC 2015 guidelines) include: fever >38°C, subacute onset, large pericardial effusion (>20 mm), failure to respond to aspirin/NSAID after 1 week, and evidence of myopericarditis (troponin elevation). These features warrant hospitalization and more intensive workup.

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9. When to Seek Emergency Care

Pericarditis is usually manageable in the outpatient setting, but these signs and symptoms demand immediate emergency evaluation:

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10. Key Research Papers

The following peer-reviewed studies and PubMed searches cover the key evidence base for pericarditis diagnosis and management:

PubMed searches for further reading:

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Connections

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