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. Emergency Warning Signs
  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 accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe (Cremer 2024 review). The 2015 ESC guideline states that the normal pericardial sac contains 10–50 mL of fluid, which lubricates the parietal and visceral 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 North America and Western Europe. With treatment, 70% to 85% of patients have a benign course, but 15% to 30% develop a recurrence (Cremer 2024 review), and a small subset develop constrictive pericarditis.

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 — a 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. (PubMed PMID: 26320112) In the Cremer 2024 review, the approximate frequencies of these findings are: typical chest pain about 90%, a new effusion (most often small) about 60%, ECG ST elevation with PR depression about 25%–50%, and a friction rub under 30%. (PubMed PMID: 39235771)


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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

The 2015 ESC guideline reports typical ECG changes in up to 60% of cases and notes that their evolution over time varies (the Cremer 2024 review gives about 25%–50% for widespread ST elevation with PR depression). The classic sequence is described in four stages:

The Spodick sign — a downsloping TP segment — was seen in 29% of patients with pericarditis and 5% of patients with ST-elevation myocardial infarction (STEMI) in a 2020 emergency-department ECG review (Witting 2020), so it is associated with pericarditis but does not rule out STEMI. (PubMed PMID: 32222321)

In the same review, the findings that best separated STEMI from pericarditis were ST depression (outside V1 and aVR), greater ST elevation in lead III than lead II, and the absence of PR depression — all three pointing toward STEMI. Low voltage and electrical alternans are associated with large pericardial effusion.

Laboratory Findings

Echocardiography

Echocardiography detects pericardial effusion and grades its size. The 2015 ESC guideline lists the echo signs of tamponade as early diastolic collapse of the right ventricle, late diastolic collapse of the right atrium, abnormal ventricular septal motion, and exaggerated respiratory variability in ventricular filling. Echo is also used to look for myocardial wall motion abnormalities that would suggest acute coronary syndrome. The American Society of Echocardiography published multimodality imaging recommendations for pericardial disease in 2013. (PubMed PMID: 26320112; PubMed PMID: 23998693)

Cardiac MRI (CMR)

CMR is used to detect pericardial inflammation when the diagnosis is uncertain. Late gadolinium enhancement (LGE) of the pericardium indicates active inflammation. CMR also assesses myocardial involvement (epicardial LGE in myopericarditis; the 2015 ESC guideline recommends CMR to confirm it), pericardial thickness, 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

The 2015 ESC guideline lists pericardiocentesis or cardiac surgery for cardiac tamponade (urgently), for symptomatic moderate-to-large effusions that do not respond to medical therapy, and when a bacterial or neoplastic cause is suspected. (PubMed PMID: 26320112) Analysis includes: exudate vs. transudate (Light's criteria), glucose, LDH, protein, cell count and differential, cultures (bacterial, TB), cytology (malignant cells), adenosine deaminase (ADA), and PCR for viruses and TB. In a 2006 meta-analysis, a pericardial-fluid ADA of 40 U/L or more had 88% sensitivity and 83% specificity for tuberculous pericarditis. (PubMed PMID: 16950165)


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6. Treatment

First-Line Anti-Inflammatory Therapy

The 2015 ESC guideline lists aspirin or NSAIDs as first-line therapy for acute pericarditis, with colchicine added on top. The doses in its table are: (PubMed PMID: 26320112)

Colchicine — Recurrence Prevention

Colchicine, added to aspirin or NSAIDs, reduced recurrence in four randomized trials:

Corticosteroids — Caution

The 2015 ESC guideline places corticosteroids as a second option and states that they favour chronicity, more recurrences and side effects. In the COPE trial, corticosteroid use was an independent risk factor for recurrence (odds ratio 4.30). (PubMed PMID: 26320112; PubMed PMID: 16186437)

Corticosteroids are often used when pericarditis does not improve with NSAIDs and colchicine (Cremer 2024 review). Where they are used, the 2015 ESC guideline recommends low-to-moderate doses (prednisone 0.2–0.5 mg/kg/day or equivalent) with a particularly slow taper. In a nonrandomized comparison of 100 patients with recurrent pericarditis, prednisone 1.0 mg/kg/day was associated with more severe side effects, recurrences and hospitalizations than 0.2–0.5 mg/kg/day (hazard ratio 3.61). (PubMed PMID: 18645054)

Anakinra and IL-1 Blockade

The 2015 ESC guideline states that IL-1 antagonists may be considered in infection-negative, corticosteroid-dependent recurrent pericarditis. In the AIRTRIP randomized-withdrawal trial, 21 patients with at least 3 previous recurrences, colchicine resistance and corticosteroid dependence received the IL-1 receptor antagonist anakinra (2 mg/kg per day, up to 100 mg) for 2 months; responders were then randomized to continue anakinra or switch to placebo. Recurrence occurred in 2 of 11 patients (18.2%) on anakinra and 9 of 10 (90%) on placebo. Transient injection-site skin reactions occurred in 20 of 21 patients. (PubMed PMID: 27825009)

Rilonacept, a once-weekly IL-1α/β "trap", was tested in the phase 3 RHAPSODY randomized-withdrawal trial: of 61 patients randomized after a response in the run-in period, recurrence occurred in 2 of 30 (7%) on rilonacept and 23 of 31 (74%) on placebo (hazard ratio 0.04). The most common adverse events were injection-site reactions and upper respiratory tract infections. (PubMed PMID: 33200890) A 2022 pharmacology review describes rilonacept as newly approved and indicated for recurrent pericarditis in adults and children 12 years and older. (PubMed PMID: 34459270)

Activity Restriction

The 2015 ESC guideline recommends restricting physical activity beyond ordinary sedentary life in non-athletes until symptoms resolve and CRP normalizes. For athletes, it recommends a minimum restriction of 3 months from the onset of the attack, with return to competitive sport only after symptoms resolve and CRP, ECG and echocardiogram have normalized. (PubMed PMID: 26320112)


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7. Natural and Lifestyle Approaches

Rest and Activity

The guideline's activity restriction is described under Treatment. The sources on this page report no trials comparing different rest regimens in pericarditis.

Nutrition and Supplements

Omega-3 fats from fatty fish, curcumin from turmeric, a Mediterranean-style eating pattern, magnesium, vitamin D, and polyphenols such as quercetin and resveratrol are often discussed for their general anti-inflammatory effects. PubMed searches (October 2026) found no randomized trial of any of them as a treatment for pericarditis, so there is no pericarditis-specific dose or effect to report. Their general research is covered on the linked Magnesium, Omega-3 Fatty Acids and Turmeric pages.

Stress and Mind-Body Practices

No trials of meditation, yoga or breathwork in pericarditis were found in PubMed (October 2026).

Factors Linked to Recurrence


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8. Complications and Prognosis

Pericardial Effusion

The 2015 ESC guideline reports pericardial effusion in up to 60% of acute pericarditis cases, generally mild; the Cremer 2024 review likewise gives about 60%, most often small. (PubMed PMID: 26320112; PubMed PMID: 39235771) In a cohort of 453 patients, a large effusion or tamponade was linked to a higher chance of a specific cause (such as tuberculosis, cancer, autoimmune disease or purulent infection; hazard ratio 2.15) and of complications (hazard ratio 2.51). (PubMed PMID: 17502574)

Cardiac Tamponade

Life-threatening hemodynamic collapse from pericardial fluid compressing cardiac chambers and preventing adequate filling. The rate of fluid accumulation matters as well as the volume — slowly accumulating effusions allow the pericardium to stretch. The 2015 ESC guideline lists urgent pericardiocentesis or cardiac surgery for tamponade.

Constrictive Pericarditis

A dreaded long-term complication — the pericardium becomes fibrosed, thickened and sometimes calcified, restricting cardiac filling. In a prospective cohort of 500 patients followed for a median of 72 months, constriction developed in 2 of 416 with idiopathic/viral pericarditis (0.48%) and in 7 of 84 with other causes (8.3%); incidence was 0.76 per 1000 person-years for idiopathic/viral cases, 31.65 for tuberculous and 52.74 for purulent pericarditis. (PubMed PMID: 21844077) The 2015 ESC guideline classes the risk as low (<1%) for idiopathic/presumed viral pericarditis, intermediate (2–5%) for immune-mediated and neoplastic causes, and high (20–30%) for bacterial causes, especially tuberculous and purulent pericarditis. Clinically it mimics right heart failure: elevated JVP, Kussmaul sign, pericardial knock, ascites, and peripheral edema. Treatment is surgical pericardiectomy (removal of the pericardium).

Recurrent Pericarditis

Recurrence is the most common complication of pericarditis (CORP trial report). The 2015 ESC guideline and the Cremer 2024 review give 15–30% after a first episode. Corticosteroid use and the absence of colchicine are linked to more recurrences (see above). The 2015 ESC guideline lists colchicine for at least 6 months in recurrent pericarditis, and IL-1 antagonists may be considered for infection-negative, corticosteroid-dependent cases.

Prognosis

Idiopathic/viral pericarditis generally has a good prognosis: with treatment, 70% to 85% of patients have a benign course, constriction occurs in under 0.5% and tamponade in under 3% (Cremer 2024 review). Across all causes in the Imazio 2007 cohort (453 patients, mean follow-up 31 months), complications occurred in 21.0%: recurrences 18.3%, tamponade 3.1% and constriction 1.5%. In a Finnish national registry of 1,361 hospital admissions for acute pericarditis, in-hospital mortality was 1.1%, rising with age and severe coinfection. (PubMed PMID: 25205801) The 2015 ESC guideline lists major predictors of a poor prognosis — fever >38°C, subacute course, a large effusion (>20 mm diastolic), cardiac tamponade, and failure of NSAIDs within 7 days — and minor predictors: myopericarditis, immunodepression, trauma, and oral anticoagulant therapy. In the Imazio 2007 cohort, fever >38 °C, a subacute course, a large effusion or tamponade, and aspirin or NSAID failure identified patients at higher risk of a specific cause or of complications.


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9. Emergency Warning Signs

Pericarditis is usually managed outside hospital, but the findings below are signs of tamponade or of the high-risk features described in the 2015 ESC guideline, which clinical sources treat as reasons for immediate emergency evaluation:


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Key Research Papers

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

  1. Imazio M, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522–1528. — ICAP trial; colchicine lowered incessant or recurrent pericarditis from 37.5% to 16.7%. — PubMed PMID: 23992557
  2. Imazio M, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011;155(7):409–414. — PubMed PMID: 21873705
  3. Imazio M, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med. 2005;165(17):1987–1991. — PubMed PMID: 16186468
  4. Imazio M, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005;112(13):2012–2016. — PubMed PMID: 16186437
  5. Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921–2964. — PubMed PMID: 26320112 (a 2025 ESC guideline on myocarditis and pericarditis has since been published: Schulz-Menger J, et al. Eur Heart J. 2025;46(40):3952–4041 — PubMed PMID: 40878297)
  6. Imazio M, et al. Indicators of poor prognosis of acute pericarditis. Circulation. 2007;115(21):2739–2744. — PubMed PMID: 17502574
  7. Imazio M, et al. Corticosteroids for recurrent pericarditis: high versus low doses: a nonrandomized observation. Circulation. 2008;118(6):667–671. — PubMed PMID: 18645054
  8. Kytö V, et al. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation. 2014;130(18):1601–1606. — PubMed PMID: 25205801
  9. Klein AL, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease. J Am Soc Echocardiogr. 2013;26(9):965–1012. — PubMed PMID: 23998693
  10. Klein AL, et al. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis. N Engl J Med. 2021;384(1):31–41 — RHAPSODY trial. — PubMed PMID: 33200890
  11. Brucato A, et al. Effect of anakinra on recurrent pericarditis among patients with colchicine resistance and corticosteroid dependence: the AIRTRIP randomized clinical trial. JAMA. 2016;316(18):1906–1912. — PubMed PMID: 27825009
  12. Imazio M, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial. Lancet. 2014;383(9936):2232–2237. — PubMed PMID: 24694983
  13. Imazio M, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011;124(11):1270–1275. — PubMed PMID: 21844077
  14. Cremer PC, Klein AL, Imazio M. Diagnosis, risk stratification, and treatment of pericarditis: a review. JAMA. 2024;332(13):1090–1100. — PubMed PMID: 39235771
  15. Witting MD, et al. Evaluation of Spodick's sign and other electrocardiographic findings as indicators of STEMI and pericarditis. J Emerg Med. 2020;58(4):562–569. — PubMed PMID: 32222321
  16. Tuon FF, et al. Adenosine deaminase and tuberculous pericarditis — a systematic review with meta-analysis. Acta Trop. 2006;99(1):67–74. — PubMed PMID: 16950165
  17. Schwier NC. Rilonacept: a newly approved treatment for recurrent pericarditis. Ann Pharmacother. 2022;56(5):572–581. — PubMed PMID: 34459270

PubMed searches for further reading:

  1. PubMed: Pericarditis diagnosis and treatment
  2. PubMed: Recurrent pericarditis colchicine
  3. PubMed: Constrictive pericarditis
  4. PubMed: Pericardial effusion tamponade
  5. PubMed: Tuberculous pericarditis
  6. PubMed: Pericarditis ECG findings

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Connections

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