Acute Pericarditis

Acute Pericarditis – A Complete Clinical Guide for Practice

Definition

Acute pericarditis is an inflammatory condition of the pericardium lasting less than 4–6 weeks. It is a common cause of acute chest pain and should always be differentiated from acute coronary syndromes.

Epidemiology

Acute pericarditis accounts for approximately 5% of emergency department visits for chest pain not related to myocardial infarction. It affects all age groups, with a slight male predominance.

Etiology

In most cases, acute pericarditis is idiopathic, presumed viral. Common causes include:

• Viral: Coxsackievirus, echovirus, influenza, COVID-19

• Bacterial: Tuberculosis (important in endemic regions), staphylococci, streptococci

• Post–myocardial injury: Early post-MI, Dressler syndrome

• Autoimmune: SLE, rheumatoid arthritis

• Metabolic: Uremia

• Neoplastic: Lung, breast, lymphoma

• Drug-induced and radiation-related

Clinical Presentation

Chest Pain

• Sharp, pleuritic chest pain

• Worse on inspiration and lying supine

• Relieved by sitting up and leaning forward

• May radiate to neck, shoulder, or trapezius ridge

Associated Symptoms

• Low-grade fever

• Dyspnea (especially if effusion present)

• Palpitations

• Fatigue

Physical Examination

Pericardial Friction Rub

• High-pitched, scratchy sound

• Best heard at left lower sternal border

• Louder with patient leaning forward

• Pathognomonic but transient

Diagnostic Criteria

Diagnosis requires at least two of the following four criteria:

1. Typical chest pain

2. Pericardial friction rub

3. Typical ECG changes

4. New or worsening pericardial effusion

Investigations

Electrocardiogram

Classic ECG evolves through four stages:

Stage 1: Diffuse concave ST elevation with PR depression

Stage 2: ST normalization

Stage 3: T-wave inversion

Stage 4: ECG normalization

Key ECG Clues

• ST elevation is diffuse (not territorial)

• PR depression in multiple leads

• No reciprocal ST depression (except aVR, V1)

Laboratory Tests

• Elevated CRP and ESR

• Mild leukocytosis

• Troponin may be mildly elevated (myopericarditis)

Echocardiography

• Assesses presence and size of pericardial effusion

• Evaluates hemodynamic compromise

• Essential to exclude cardiac tamponade

Advanced Imaging

• Cardiac MRI: Detects pericardial inflammation and edema

• CT chest: Useful in suspected neoplastic or tuberculous disease

Differential Diagnosis

• Acute myocardial infarction

• Pulmonary embolism

• Aortic dissection

• Pleuritis

• Gastroesophageal reflux disease

Risk Stratification

High-Risk Features (Require Hospital Admission)

• Fever >38°C

• Subacute onset

• Large pericardial effusion

• Cardiac tamponade

• Immunosuppression

• Trauma

• Failure to respond to NSAIDs

• Elevated troponin (myopericarditis)

Management

First-Line Therapy

NSAIDs

• Ibuprofen 600–800 mg three times daily

• Aspirin preferred post-MI (750–1000 mg three times daily)

• Continue until symptom resolution and CRP normalization

Colchicine

• 0.5 mg once daily (<70 kg)

• 0.5 mg twice daily (≥70 kg)

• Duration: 3 months

• Reduces recurrence by ~50%

Gastroprotection

• Proton pump inhibitor with NSAIDs

Second-Line Therapy

Corticosteroids

• Reserved for refractory cases or contraindications to NSAIDs

• Low dose prednisone (0.2–0.5 mg/kg/day)

• Associated with higher recurrence rates

Treatment of Specific Causes

• Tuberculous pericarditis: Anti-TB therapy ± steroids

• Bacterial pericarditis: IV antibiotics and drainage

• Uremic pericarditis: Intensified dialysis

Activity Restriction

• Avoid strenuous activity until symptom and CRP resolution

• Athletes: Minimum restriction of 3 months

Complications

• Pericardial effusion

• Cardiac tamponade

• Recurrent pericarditis

• Constrictive pericarditis (rare in acute viral cases)

Prognosis

Overall prognosis is excellent in idiopathic and viral pericarditis. Most patients recover completely with appropriate therapy. Recurrence occurs in 15–30% without colchicine and significantly less with its use.

Guideline Perspective

Management recommendations are based on the European Society of Cardiology guidelines, emphasizing NSAIDs plus colchicine as standard first-line therapy and risk-based hospitalization.

Key Takeaway

Acute pericarditis is a clinical diagnosis supported by ECG and imaging. Early recognition, correct differentiation from myocardial infarction, and guideline-directed therapy ensure excellent outcomes and prevent recurrence.

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