Pericarditis – Quick Consult
Last Updated / Reviewed: June 2024

Causes of Pericarditis
Key History
Key Physical Exam
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications 

Causes of Pericarditis

  • Idiopathic – most common cause of acute pericarditis
  • Infectious
    • Viral – second most common cause acute pericarditis. Peak occurrences in fall and spring.
    • Bacterial – causes purulent pericarditis
    • Tubercular
    • Fungal
    • Parasitic
  • Inflammatory
    • Rheumatoid arthritis
    • Systemic lupus erythematosus
    • Scleroderma
    • Rheumatic fever
    • Sarcoidosis
  • Metabolic
    • Uremia/renal failure
    • Hypothyroidism
    • Cholesterol pericarditis
  • Cardiovascular disease
    • Myocardial infarction
    • Dressler's syndrome
    • Aortic dissection
  • Neoplasm
  • Iatrogenic
    • Drugs
    • Irradiation
    • Postpericardiotomy syndrome
  • Trauma
  • Other
    • Sjögren's syndrome
    • Ankylosing spondylitis
    • Inflammatory bowel disease
    • Reiter syndrome
    • Behçet's disease
    • Whipple's disease
    • Familial Mediterranean fever
    • Serum sickness
    • Vasculitis
    • Wegner's granulomatosis
    • Mixed connective tissue disease
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Key History

  • Chest pain is often precordial.
  • Chest tightness
  • Cough
  • Fever
  • Myalgia
  • Pain may be abrupt in onset.
  • Pain improves by leaning forward.
  • Pain worsens with movement, lying flat, and on inspiration.
  • Pain may radiate to trapezius area.
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Key Physical Exam

  • Friction rub heard best over left lower sternal border
  • Tachycardia
  • Tachypnea
  • Rales
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Differential Diagnosis

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Diagnostic Testing

Current recommendations include:

The diagnostic testing for pericarditis involves a combination of clinical evaluation and imaging modalities.

  • According to the American Society of Echocardiography and endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography, echocardiography is a key imaging tool in the diagnosis of acute pericarditis. Echocardiographic findings that support the diagnosis include pericardial effusion, increased pericardial brightness, and in some cases, pericardial thickening.
  • Cardiac magnetic resonance (CMR) imaging is also useful, particularly when there is diagnostic uncertainty or to determine the presence and extent of myocardial and pericardial inflammation and fibrosis.
  • In addition to imaging, the diagnosis of pericarditis is supported by clinical features such as chest pain that improves with sitting up or leaning forward, a pericardial friction rub, and typical electrocardiogram (ECG) changes like diffuse ST-segment elevation and PR segment depression.
  • Elevated inflammatory markers such as C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) can also be supportive of the diagnosis.
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Clinical Risk and Safety Pearls

  • Features associated with higher risk of complications include:
    • High fever and leukocytosis
    • Evidence suggesting tamponade
    • Large pericardial effusion
    • Acute trauma
    • Subacute symptoms
    • Immunosuppressed state
    • History of anticoagulant therapy
    • Failure to respond to 7 days NSAID therapy
  • Patients with any high-risk features above should be admitted.

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Treatment

Current recommendations include:
  • Identify the cause if possible and treat the underlying disorder if indicated.
  • Consider pericardiocentesis if:
    • Moderate to severe tamponade is present.
    • Purulent, tuberculous, or neoplastic pericarditis is suspected.
    • A persistent symptomatic pericardial effusion is present.
  • NSAIDs are considered the first-line therapy for symptom relief and inflammation reduction. Ibuprofen is commonly used, with a suggested dosage of 300-800 mg three to four times daily, and should be tapered over several weeks to prevent recurrence.
  • Colchicine is recommended as an adjunctive therapy to NSAIDs to reduce the risk of recurrence and to treat the initial episode. The dosage of colchicine is typically 0.5 mg twice daily for patients weighing more than 70 kg and 0.5 mg once daily for those weighing less than 70 kg, with treatment duration of 3 months.
  • Corticosteroids are reserved as a second-line therapy for patients who do not respond to, are intolerant of, or have contraindications to NSAIDs and colchicine. Low-dose corticosteroids are preferred over high doses to minimize the risk of recurrence and adverse effects.
  • Bacterial, purulent, and tuberculous pericarditis must be treated with antibiotics and may need surgical drainage.
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Complications

  • Tamponade
  • Recurrent pericarditis

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  3. Ismail TF. Acute pericarditis: Update on diagnosis and management. Clin Med (Lond). 2020 Jan;20(1):48-51. doi: 10.7861/clinmed.cme.20.1.4. PMID: 31941732; PMCID: PMC6964178.
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  5. Melendo-Viu M, Marchán-Lopez Á, Guarch CJ, Roubín SR, Abu-Assi E, Meneses RT, Ynsaurriaga FA, Hernandez AV, Bueno H. A systematic review and meta-analysis of randomized controlled trials evaluating pharmacologic therapies for acute and recurrent pericarditis. Trends Cardiovasc Med. 2023 Jul;33(5):319-326. doi: 10.1016/j.tcm.2022.02.001. Epub 2022 Feb 5. PMID: 35131416.
  6. Niemann J. Cardiomyopathies and Pericardial Disease. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016.
  7. Writing Committee Members; Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-e285. doi: 10.1016/j.jacc.2021.07.053. Epub 2021 Oct 28. PMID: 34756653.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
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