Pericarditis

Pericarditis is an inflammation of the pericardium, the fibrous sac surrounding the heart. It often presents with a sudden onset of sharp chest pain, which can radiate to the shoulders, neck, or back. The pain is typically relieved by sitting up and exacerbated by lying down or deep breathing.

Other symptoms can include fever, weakness, palpitations, and shortness of breath. Pericarditis is most commonly caused by viral infections but can also result from bacterial infections, myocardial infarction, cancer, autoimmune disorders, and chest trauma.

An ECG showing pericarditis, with ST elevation in multiple leads and slight reciprocal ST depression in aVR

Signs and Symptoms

The hallmark of pericarditis is sharp, pleuritic chest pain that can radiate to the trapezius ridge. This pain is characteristically relieved by sitting up or bending forward and worsened by lying down or inspiration. The pain may resemble that of angina but typically differs in its positional nature. Additional symptoms can include dry cough, fever, fatigue, and anxiety.

During a physical examination, a friction rub heard with a stethoscope over the lower left sternal border is a classic sign. Other signs may include distress, diaphoresis, and signs of heart failure such as pericardial tamponade. Electrocardiograms often show widespread concave ST elevation and PR depression.

Complications

Pericarditis can lead to pericardial effusion and cardiac tamponade. Cardiac tamponade is a medical emergency characterised by decreased alertness, pulsus paradoxus, low blood pressure, jugular vein distention, and distant heart sounds. Diagnosis can be confirmed with trans-thoracic echocardiography, which shows large pericardial effusion and diastolic collapse of the right heart chambers.

Figure A shows the location of the heart and a normal heart and pericardium (the sac surrounding the heart). The inset image is an enlarged cross-section of the pericardium that shows its two layers of tissue and the fluid between the layers. Figure B shows the heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.

Causes

In the developing world, tuberculosis is a common cause of pericarditis, whereas viral infections are responsible for most cases in the developed world. Other infectious causes include bacterial and fungal infections. Non-infectious causes include autoimmune diseases, myocardial infarction, chest trauma, uraemia, cancer, certain medications, and radiation exposure.

Diagnosis

Diagnosis is primarily based on clinical presentation and electrocardiogram findings. Laboratory tests may show increased blood urea nitrogen or creatinine in uraemic pericarditis, and elevated cardiac markers if there is concurrent myocardial infarction. Imaging modalities such as echocardiography, chest X-ray, and MRI can assist in diagnosis and assessing complications like pericardial effusion.

Diffuse ST elevation in a young male due to myocarditis / pericarditis.

An ECG showing pericarditis. Note the ST elevation in multiple leads with slight reciprocal ST depression in aVR.

Treatment

Initial treatment for viral or idiopathic pericarditis involves non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, and colchicine to reduce recurrence risk. Severe cases may require antibiotics for bacterial causes, corticosteroids, or pericardiocentesis for large effusions. Recurrent pericarditis resistant to standard treatments may benefit from interleukin-1 inhibitors like anakinra. In severe cases, surgical removal of the pericardium (pericardiectomy) may be necessary, although it carries a significant risk of mortality.

Ultrasounds showing a pericardial effusion in someone with pericarditis.

A pericardial effusion as seen on CXR in someone with pericarditis.

Self-assessment MCQs (single best answer)

What is the hallmark symptom of pericarditis?

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Which position typically relieves the chest pain associated with pericarditis?

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What is a classic sign of pericarditis that can be heard with a stethoscope?

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Which imaging modality is most useful for diagnosing pericardial effusion?

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What is the most common cause of pericarditis in the developed world?

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Which complication of pericarditis is characterised by decreased alertness, low blood pressure, and jugular vein distention?

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Which drug is commonly used as part of initial treatment for viral or idiopathic pericarditis?

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What finding is typically seen on an ECG in a patient with pericarditis?

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Which of the following conditions is NOT a cause of pericarditis?

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What is a potential treatment for recurrent pericarditis resistant to standard treatments?

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