Pericarditis

Overview

Pericarditis is inflammation of the pericardium, a thin, two-layered membrane that surrounds and protects the heart. The pericardium consists of two layers: the visceral pericardium (epicardium) that directly covers the heart, and the parietal pericardium that forms the outer layer. Between these layers is a small space containing a small amount of lubricating fluid that allows the heart to beat smoothly.

When the pericardium becomes inflamed, it can cause the layers to rub against each other, producing the characteristic sharp, stabbing chest pain associated with pericarditis. This condition can be acute (sudden onset and short duration) or chronic (long-lasting or recurrent). Acute pericarditis is more common and typically resolves within days to weeks with appropriate treatment.

Pericarditis affects people of all ages but is most commonly seen in men aged 20-50 years. The condition can range from mild and self-limiting to severe and life-threatening, depending on the underlying cause and whether complications develop. Most cases of acute pericarditis are idiopathic (unknown cause) or viral in origin and have an excellent prognosis with proper treatment.

While pericarditis itself is not usually dangerous, it can sometimes lead to serious complications such as cardiac tamponade (fluid accumulation that compresses the heart) or constrictive pericarditis (scarring that restricts heart movement). Early recognition and appropriate treatment are important to prevent these complications and ensure optimal outcomes.

Symptoms

The symptoms of pericarditis can vary depending on the type and severity of inflammation. The hallmark symptom is chest pain, but other cardiac and systemic symptoms may also be present.

Primary Symptoms

Chest Pain Characteristics

The chest pain in pericarditis has distinctive features:

• Location: Usually central or left-sided chest pain
• Quality: Sharp, stabbing, or knife-like (different from heart attack pain)
• Radiation: May spread to the left shoulder, neck, arm, or back
• Positional: Worse when lying flat, better when sitting up and leaning forward
• Breathing-related: Often worsens with deep inspiration (pleuritic)
• Movement-related: May worsen with coughing, swallowing, or body movement
• Duration: Can be constant or intermittent

Associated Symptoms

• Chest tightness or pressure sensation
• Lower body pain - referred pain patterns
• Fatigue and weakness
• Low-grade fever (in some cases)
• Dry cough
• Anxiety or feeling of impending doom
• Difficulty finding comfortable positions

Symptoms by Type

Acute Pericarditis

• Sudden onset of sharp chest pain
• Pain that changes with position and breathing
• May have fever, especially if infectious cause
• Symptoms typically last days to weeks
• May have preceding viral illness symptoms

Chronic Pericarditis

• Persistent or recurrent chest discomfort
• Less intense pain than acute form
• Gradual onset of symptoms
• May develop signs of heart failure if constrictive
• Symptoms may be present for months

Recurrent Pericarditis

• Episodes of acute symptoms separated by symptom-free periods
• Similar pain characteristics to initial episode
• May occur weeks to months after initial episode
• Often triggered by stress, illness, or medication changes

Warning Signs of Complications

Cardiac Tamponade

• Severe shortness of breath
• Rapid heart rate
• Low blood pressure
• Swelling in legs, ankles, or abdomen
• Feeling faint or dizzy
• Difficulty breathing when lying down

Constrictive Pericarditis

• Progressive shortness of breath
• Swelling of legs, ankles, and abdomen
• Fatigue and weakness
• Prominent neck veins
• Abdominal bloating
• Exercise intolerance

Symptoms That Require Immediate Attention

• Severe, crushing chest pain (may indicate heart attack)
• Sudden, severe shortness of breath
• Fainting or loss of consciousness
• Signs of shock (low blood pressure, rapid pulse, cold skin)
• High fever with severe chest pain
• Difficulty breathing when sitting up

Causes

Pericarditis can result from various underlying conditions or may occur without an identifiable cause. Understanding the potential causes helps guide appropriate treatment and prevention strategies.

Idiopathic Pericarditis

• Most common type: Accounts for 80-90% of cases
• Unknown cause: No specific trigger identified
• Presumed viral: Often assumed to be viral even without confirmation
• Good prognosis: Usually responds well to treatment
• Recurrence risk: 15-30% may have recurrent episodes

Infectious Causes

Viral Infections

• Coxsackievirus: Most common viral cause
• Echovirus: Another common enterovirus
• Epstein-Barr virus (EBV): Can cause pericarditis during acute infection
• Cytomegalovirus (CMV): Especially in immunocompromised patients
• Influenza virus: During seasonal outbreaks
• Adenovirus: Can affect children and adults
• COVID-19: Emerging cause during pandemic

Bacterial Infections

• Tuberculosis: Important cause worldwide, especially in endemic areas
• Staphylococcus aureus: Can cause purulent pericarditis
• Streptococcus pneumoniae: May follow pneumonia
• Haemophilus influenzae: Rare but serious
• Other bacteria: Various gram-positive and gram-negative organisms

Other Infectious Agents

• Fungal infections: Histoplasmosis, candida (in immunocompromised)
• Parasitic infections: Echinococcosis, amebiasis
• Rickettsial diseases: Q fever, Rocky Mountain spotted fever

Non-Infectious Causes

Autoimmune and Inflammatory Conditions

• Systemic lupus erythematosus (SLE): Can involve pericardium
• Rheumatoid arthritis: May cause pericardial inflammation
• Systemic sclerosis (scleroderma): Pericardial involvement common
• Inflammatory bowel disease: Crohn's disease, ulcerative colitis
• Behçet's disease: Can affect multiple organs including heart
• Sarcoidosis: Granulomatous disease affecting heart

Malignancy

• Primary pericardial tumors: Mesothelioma (rare)
• Metastatic disease: Lung cancer, breast cancer, lymphoma
• Hematologic malignancies: Leukemia, lymphoma
• Treatment-related: Radiation therapy, chemotherapy

Medical Procedures and Trauma

• Cardiac surgery: Post-cardiac injury syndrome
• Percutaneous interventions: Cardiac catheterization, ablation
• Chest trauma: Blunt or penetrating injury
• Radiation therapy: For chest malignancies
• Pacemaker implantation: Rarely causes pericarditis

Drug-Induced Pericarditis

• Hydralazine: Anti-hypertensive medication
• Procainamide: Anti-arrhythmic drug
• Isoniazid: Anti-tuberculosis medication
• Phenytoin: Anti-seizure medication
• Penicillin: High-dose intravenous use
• Immunotherapy agents: Checkpoint inhibitors

Metabolic and Other Causes

• Uremia: End-stage kidney disease
• Hypothyroidism: Severe cases
• Gout: Uric acid crystal deposition
• Aortic dissection: Extension into pericardium
• Pulmonary embolism: Rarely causes pericarditis

Post-Myocardial Infarction

Early Pericarditis

• Occurs within days of heart attack
• Direct inflammation from myocardial necrosis
• Usually resolves with standard treatment

Dressler's Syndrome

• Delayed autoimmune response
• Occurs weeks to months after MI
• May recur and require immunosuppression

Risk Factors for Specific Causes

• Geographic factors: TB endemic areas
• Immunocompromised state: HIV, organ transplant
• Recent illness: Upper respiratory infections
• Age factors: Viral more common in young adults
• Gender factors: Some autoimmune causes more common in women
• Occupational exposure: Asbestos (mesothelioma risk)

Risk Factors

Several factors can increase the likelihood of developing pericarditis or influence its severity and course. Understanding these risk factors helps in prevention and management strategies.

Demographic Risk Factors

• Age: Most common in adults 20-50 years old
• Gender: Men affected more frequently than women (2:1 ratio)
• Geographic location: Higher rates in areas with endemic tuberculosis
• Seasonal variation: Viral causes more common in fall and winter

Medical History Risk Factors

Previous Cardiac Events

• Prior myocardial infarction: Risk of early or late pericarditis
• Previous pericarditis: 15-30% recurrence rate
• Cardiac surgery: Post-operative pericardial irritation
• Cardiac procedures: Catheterization, ablation, device implantation

Autoimmune and Inflammatory Conditions

• Systemic lupus erythematosus: Pericardial involvement in 25-50%
• Rheumatoid arthritis: Increased risk of pericardial disease
• Scleroderma: Pericardial involvement common
• Inflammatory bowel disease: Extra-intestinal manifestation
• Thyroid disorders: Both hyper- and hypothyroidism

Infectious Disease Risk Factors

• Recent viral illness: Upper respiratory infections
• Tuberculosis exposure: Travel to or residence in endemic areas
• HIV infection: Increased risk of opportunistic infections
• Immunocompromised state: Organ transplant, cancer treatment
• Close contact exposure: Viral outbreaks in communities

Medication-Related Risk Factors

• Hydralazine use: Long-term anti-hypertensive therapy
• Procainamide: Anti-arrhythmic medication
• Anti-tuberculosis drugs: Isoniazid therapy
• Anticoagulants: May increase risk of pericardial bleeding
• Immunotherapy: Cancer treatment with checkpoint inhibitors
• High-dose penicillin: Intravenous administration

Cancer-Related Risk Factors

• Lung cancer: Direct extension or metastasis
• Breast cancer: Metastatic spread to pericardium
• Lymphoma: Mediastinal involvement
• Leukemia: Infiltration of pericardium
• Radiation therapy: Chest radiation for various cancers
• Chemotherapy: Certain agents cardiotoxic

Lifestyle and Environmental Risk Factors

• Stress: Physical or emotional stress may trigger episodes
• Poor nutrition: May affect immune function
• Smoking: May increase infection risk
• Alcohol use: Heavy use may compromise immunity
• Sleep deprivation: Affects immune system function
• Travel: Exposure to endemic infectious diseases

Genetic and Familial Risk Factors

• Family history: Autoimmune diseases in relatives
• Genetic syndromes: Certain hereditary conditions
• HLA associations: Certain tissue types may increase risk
• Familial Mediterranean fever: Genetic autoinflammatory disease

Occupational Risk Factors

• Healthcare workers: Increased exposure to infectious agents
• Asbestos exposure: Risk of pericardial mesothelioma
• Laboratory workers: Exposure to tuberculosis
• International travel: Exposure to endemic diseases

Risk Factors for Complications

Cardiac Tamponade Risk

• Malignant pericarditis
• Tuberculous pericarditis
• Purulent (bacterial) pericarditis
• Post-cardiac surgery
• Trauma to chest
• Anticoagulant use

Chronic/Constrictive Pericarditis Risk

• Tuberculosis (highest risk)
• Bacterial pericarditis
• Radiation therapy
• Cardiac surgery
• Autoimmune diseases
• Recurrent pericarditis

Protective Factors

• Good general health: Strong immune system
• Vaccination: Prevention of some viral infections
• Prompt medical care: Early treatment of infections
• Medication compliance: Proper management of chronic conditions
• Healthy lifestyle: Regular exercise, good nutrition
• Stress management: Techniques to reduce physical and emotional stress

Modifiable vs. Non-Modifiable Risk Factors

Modifiable

• Management of autoimmune diseases
• Lifestyle factors (stress, nutrition, sleep)
• Medication management
• Infection prevention measures
• Prompt treatment of illnesses

Non-Modifiable

• Age and gender
• Genetic predisposition
• History of previous cardiac events
• Necessary medical treatments (surgery, radiation)
• Geographic location

Diagnosis

Diagnosing pericarditis requires a combination of clinical assessment, electrocardiography, imaging studies, and laboratory tests. Early and accurate diagnosis is important for appropriate treatment and monitoring for complications.

Clinical Assessment

History Taking

• Chest pain characteristics: Sharp, positional, pleuritic
• Recent illness: Viral infections, flu-like symptoms
• Medical history: Autoimmune diseases, cancer, kidney disease
• Medications: Recent changes or known cardiotoxic drugs
• Family history: Autoimmune or inflammatory conditions
• Recent procedures: Cardiac surgery, catheterization
• Travel history: Exposure to endemic infections

Physical Examination

• Vital signs: Fever, blood pressure, heart rate
• Pericardial friction rub: Pathognomonic scratchy sound (present in ~60%)
• Heart sounds: May be distant if pericardial effusion present
• Jugular venous pressure: May be elevated
• Peripheral edema: Signs of right heart failure
• Pulsus paradoxus: Drop in systolic BP >10 mmHg with inspiration

Diagnostic Criteria

Pericarditis diagnosis requires at least 2 of the following 4 criteria:

• Characteristic chest pain: Sharp, positional, pleuritic
• Pericardial friction rub: On physical examination
• ECG changes: Widespread ST elevation or PR depression
• Pericardial effusion: New or worsening on echocardiogram

Electrocardiogram (ECG)

Classic ECG Changes (4 stages)

• Stage 1: Widespread ST elevation (concave up) with PR depression
• Stage 2: Normalization of ST and PR segments
• Stage 3: T wave inversion
• Stage 4: Return to normal (may take weeks to months)

ECG Features

• ST elevation in multiple leads (unlike MI pattern)
• PR segment depression (most specific finding)
• Absence of reciprocal ST depression
• QRS complexes remain normal
• T wave inversions develop later

Imaging Studies

Echocardiography

• Primary imaging test: Should be performed in all cases
• Pericardial effusion: Detects fluid around heart
• Cardiac tamponade: Signs of hemodynamic compromise
• Wall motion: Usually normal in pure pericarditis
• Doppler studies: Assess filling patterns

Advanced Imaging

• CT scan: Detailed pericardial anatomy, calcification
• Cardiac MRI: Pericardial inflammation, thickness, enhancement
• Chest X-ray: May show enlarged cardiac silhouette
• PET scan: Metabolic activity in pericardium (research)

Laboratory Tests

Routine Tests

• Complete blood count: Check for infection, anemia
• ESR and CRP: Markers of inflammation
• Troponin: May be mildly elevated (myopericarditis)
• BUN and creatinine: Assess kidney function
• Thyroid function: Rule out thyroid disease

Specific Tests Based on Suspected Cause

• Viral serologies: If viral cause suspected
• ANA, anti-dsDNA: For autoimmune causes
• Tuberculin skin test/IGRA: If TB suspected
• Blood cultures: If bacterial infection suspected
• Tumor markers: If malignancy suspected

Pericardial Fluid Analysis

Pericardiocentesis may be performed for diagnostic or therapeutic purposes:

Indications for Pericardiocentesis

• Cardiac tamponade (emergency)
• Large pericardial effusion with symptoms
• Suspected bacterial, tuberculous, or malignant pericarditis
• Recurrent pericarditis with effusion

Pericardial Fluid Tests

• Appearance: Clear, bloody, purulent
• Cell count and differential: WBC types
• Protein and LDH: Exudate vs. transudate
• Glucose: Low in bacterial/tuberculous
• Gram stain and culture: Bacterial identification
• AFB stain and culture: Tuberculosis
• Cytology: Malignant cells
• Adenosine deaminase: Elevated in TB

Differential Diagnosis

• Acute coronary syndrome: Different ECG pattern, troponin levels
• Pulmonary embolism: Different symptoms, D-dimer, CT-PA
• Pneumonia: Chest X-ray, clinical presentation
• Pleuritis: Pleural friction rub, imaging
• Aortic dissection: CT angiography, clinical presentation
• Gastroesophageal reflux: Response to antacids
• Musculoskeletal pain: Reproducible with palpation

Risk Stratification

Low-Risk Features

• Young age without comorbidities
• Gradual onset
• No fever
• No pericardial effusion
• Response to NSAIDs

High-Risk Features

• High fever (>38°C)
• Large pericardial effusion
• Cardiac tamponade
• Immunocompromised state
• Traumatic etiology
• Oral anticoagulant therapy
• Myopericarditis
• Poor response to NSAIDs after 1 week

Monitoring and Follow-up

• Clinical response: Symptom improvement
• ECG changes: Evolution of abnormalities
• Inflammatory markers: CRP, ESR trends
• Echocardiogram: Resolution of effusion
• Recurrence monitoring: Long-term follow-up

Treatment Options

Treatment of pericarditis focuses on reducing inflammation, relieving symptoms, and preventing complications. The approach varies based on the underlying cause, severity, and risk of complications.

First-Line Treatment

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Ibuprofen: 400-800 mg every 8 hours (preferred)
• Aspirin: 750-1000 mg every 8 hours
• Indomethacin: 25-50 mg every 8 hours
• Duration: Typically 1-2 weeks, then taper
• Monitoring: Kidney function, GI symptoms

Colchicine

• Mechanism: Anti-inflammatory, reduces recurrence
• Dosing: 0.5 mg twice daily (adjust for weight/kidney function)
• Duration: 3 months for first episode
• Benefits: Reduces recurrence risk by 50%
• Side effects: GI upset, diarrhea

Combination Therapy

NSAID + Colchicine is now considered optimal first-line treatment:

• Faster symptom resolution
• Reduced recurrence rates
• Lower risk of complications
• Better long-term outcomes

Second-Line Treatment

Corticosteroids

Reserved for specific indications:

• Contraindications to NSAIDs: Kidney disease, GI bleeding
• Autoimmune causes: SLE, other connective tissue diseases
• Pregnancy: When NSAIDs contraindicated
• Refractory cases: No response to NSAIDs/colchicine

Corticosteroid Regimens

• Prednisone: 0.2-0.5 mg/kg/day initially
• Maximum dose: Usually 60-80 mg daily
• Duration: Slow taper over weeks to months
• Monitoring: Blood glucose, blood pressure, bone density
• Combination: Always use with colchicine

Treatment by Etiology

Idiopathic/Viral Pericarditis

• NSAIDs + colchicine
• Symptomatic treatment
• Rest and activity restriction
• Follow-up monitoring

Bacterial Pericarditis

• Antibiotics: Broad-spectrum initially, then targeted
• Drainage: Pericardiocentesis or surgical drainage
• NSAIDs: After infection controlled
• Hospitalization: Required for monitoring

Tuberculous Pericarditis

• Anti-TB therapy: Standard 4-drug regimen
• Duration: 6 months minimum
• Corticosteroids: May reduce constrictive risk
• Monitoring: For constrictive pericarditis development

Autoimmune Pericarditis

• Treat underlying condition: Disease-modifying drugs
• Corticosteroids: Often first-line
• Immunosuppressants: Methotrexate, azathioprine
• Biologics: For refractory cases

Treatment of Complications

Cardiac Tamponade

• Emergency pericardiocentesis: Immediate drainage
• IV fluids: Support preload
• Avoid diuretics: Can worsen hemodynamics
• Monitor closely: For reaccumulation
• Surgical drainage: If recurrent

Recurrent Pericarditis

• Colchicine: Long-term use (6 months to years)
• Low-dose corticosteroids: If needed
• Immunosuppressants: Methotrexate, azathioprine
• Biologics: Anakinra (IL-1 receptor antagonist)
• Lifestyle modifications: Stress reduction, exercise limitation

Constrictive Pericarditis

• Medical therapy: Diuretics for symptom relief
• Pericardiectomy: Surgical removal of pericardium
• Timing: Before irreversible heart failure
• Risk assessment: Surgical candidacy evaluation

Advanced Therapies

Immunosuppressive Agents

• Methotrexate: 10-15 mg weekly
• Azathioprine: 2-3 mg/kg/day
• Mycophenolate mofetil: 1-2 g daily
• Cyclosporine: For severe cases

Biologic Therapies

• Anakinra: IL-1 receptor antagonist
• Rituximab: B-cell depletion
• Infliximab: TNF-alpha inhibitor
• IVIG: Intravenous immunoglobulin

Supportive Care

• Pain management: Positioning, heat/cold therapy
• Activity restriction: Avoid strenuous exercise
• Monitoring: Regular follow-up appointments
• Patient education: Recognition of recurrence
• Psychological support: For chronic/recurrent cases

Monitoring During Treatment

• Symptom assessment: Pain levels, activity tolerance
• Laboratory monitoring: CRP, ESR, kidney function
• ECG changes: Resolution of abnormalities
• Echocardiogram: Pericardial effusion resolution
• Drug side effects: NSAID toxicity, steroid effects

Treatment Duration and Tapering

• NSAIDs: 1-2 weeks, then gradual taper
• Colchicine: 3 months first episode, 6 months recurrent
• Corticosteroids: Slow taper over weeks to months
• Monitoring: For symptom recurrence during taper
• Individualization: Adjust based on response

Prevention

While many cases of pericarditis cannot be prevented, certain strategies can reduce the risk of developing the condition or experiencing recurrent episodes. Prevention focuses on addressing modifiable risk factors and managing underlying conditions.

Primary Prevention

Infection Prevention

• Vaccination: Stay current with recommended vaccines
• Hand hygiene: Regular handwashing, especially during viral season
• Avoid sick contacts: Limit exposure during outbreaks
• Strengthen immunity: Adequate sleep, nutrition, exercise
• Prompt treatment: Seek care for respiratory infections

Lifestyle Modifications

• Stress management: Regular exercise, relaxation techniques
• Adequate sleep: 7-9 hours nightly for immune function
• Balanced nutrition: Support immune system function
• Avoid smoking: Reduces infection and inflammatory risk
• Moderate alcohol: Excessive use compromises immunity

Secondary Prevention (Preventing Recurrence)

Colchicine Prophylaxis

• Standard therapy: 0.5 mg twice daily
• Duration: 6 months for recurrent episodes
• Effectiveness: Reduces recurrence by 50-75%
• Weight-based dosing: Adjust for body weight <70 kg
• Monitoring: GI tolerance, drug interactions

Activity Modifications

• Exercise restrictions: Avoid competitive sports during acute phase
• Gradual return: Progressive activity increase
• Sports clearance: Medical evaluation before resuming athletics
• Long-term monitoring: Regular cardiac assessments

Management of Underlying Conditions

Autoimmune Diseases

• Disease control: Optimal management of SLE, RA, etc.
• Medication compliance: Consistent use of prescribed treatments
• Regular monitoring: Frequent rheumatology follow-up
• Early intervention: Prompt treatment of flares

Kidney Disease

• Optimal dialysis: Adequate uremia clearance
• Fluid management: Avoid volume overload
• Blood pressure control: Target appropriate levels
• Medication adjustments: Dose modifications for kidney function

Medication-Related Prevention

Drug-Induced Pericarditis Prevention

• Medication review: Regular assessment of need
• Alternative agents: Use less cardiotoxic options when possible
• Monitoring: Watch for early signs of cardiac effects
• Dose optimization: Use lowest effective doses

Anticoagulation Management

• Risk assessment: Bleeding vs. thrombotic risk
• INR monitoring: Maintain therapeutic range
• Drug interactions: Avoid medications that increase bleeding risk
• Activity restrictions: Avoid high-risk activities

Post-Procedural Prevention

After Cardiac Surgery

• Anti-inflammatory prophylaxis: Colchicine post-operatively
• Monitoring: Watch for post-cardiac injury syndrome
• Early mobilization: Appropriate activity levels
• Follow-up care: Regular post-operative visits

After Cardiac Procedures

• Gentle technique: Minimize pericardial trauma
• Prophylactic medications: Consider anti-inflammatory agents
• Post-procedure monitoring: Watch for delayed complications

Environmental and Occupational Prevention

• Travel precautions: Vaccinations for endemic areas
• Occupational safety: Protect against asbestos, infections
• Radiation protection: Minimize unnecessary exposure
• Chemical exposure: Use appropriate protective equipment

Cancer-Related Prevention

• Screening programs: Early detection of malignancies
• Radiation planning: Minimize cardiac exposure
• Chemotherapy protocols: Use cardioprotective agents when available
• Cardiac monitoring: Regular assessments during treatment

Patient Education

Recognition of Symptoms

• Warning signs: Chest pain characteristics
• When to seek care: Worsening symptoms
• Recurrence signs: Return of typical symptoms
• Emergency symptoms: Severe dyspnea, syncope

Medication Compliance

• Importance of adherence: Preventing recurrence
• Side effect management: When to contact provider
• Drug interactions: Medications to avoid
• Tapering protocols: Importance of gradual reduction

Special Populations

Pregnancy

• Preconception counseling: Risk assessment
• Medication adjustments: Pregnancy-safe options
• Monitoring: Increased surveillance
• Delivery planning: Multidisciplinary approach

Athletes

• Pre-participation screening: Cardiac evaluation
• Return-to-play protocols: Gradual activity progression
• Long-term monitoring: Regular cardiac assessments
• Education: Recognition of cardiac symptoms

Long-term Monitoring

• Regular follow-up: Scheduled cardiology visits
• Symptom surveillance: Patient-reported outcomes
• Imaging surveillance: Periodic echocardiograms
• Laboratory monitoring: Inflammatory markers
• Quality of life assessment: Functional status evaluation

When to See a Doctor

Pericarditis symptoms can mimic other serious cardiac conditions, and complications can develop rapidly. Knowing when to seek medical attention is crucial for proper diagnosis and treatment.

Seek Emergency Medical Care (Call 911) If You Experience:

• Severe chest pain: Crushing, pressure-like pain suggesting heart attack
• Difficulty breathing: Severe shortness of breath at rest
• Fainting or near-fainting: Loss of consciousness or severe lightheadedness
• Rapid heart rate: Heart rate >120 beats per minute at rest
• Signs of shock: Cold, clammy skin, weakness, confusion
• Inability to lie flat: Must sit upright to breathe
• Swelling of face or neck: May indicate tamponade

See a Doctor Promptly (Same Day) For:

Characteristic Pericarditis Symptoms

• Sharp chest pain: Worse with breathing or lying flat
• Positional pain: Better when sitting up and leaning forward
• Pleuritic pain: Worsens with deep breathing or coughing
• Radiating pain: To shoulder, neck, arm, or back
• New heart palpitations: Awareness of irregular heartbeat

Associated Symptoms

• Fever with chest pain
• Persistent fatigue with chest discomfort
• Dry cough that won't resolve
• Mild shortness of breath with exertion
• Anxiety or feeling of unease with chest symptoms

Schedule Medical Appointment Within a Few Days For:

• Mild chest discomfort: Intermittent, not severe
• Recent viral illness: With subsequent chest symptoms
• Family history: Of autoimmune or inflammatory diseases
• Medication concerns: New medications with cardiac side effects
• Follow-up symptoms: After recent cardiac procedure

High-Risk Situations Requiring Immediate Evaluation

If You Have History Of:

• Previous pericarditis: Higher risk of complications
• Heart surgery: Risk of post-cardiac injury syndrome
• Cancer treatment: Radiation or chemotherapy
• Autoimmune disease: Lupus, rheumatoid arthritis
• Kidney disease: Especially if on dialysis
• Taking blood thinners: Risk of pericardial bleeding

Recent Procedures or Events

• Cardiac catheterization within past month
• Pacemaker or defibrillator implantation
• Chest trauma or injury
• Recent heart attack
• Started new medications

Red Flag Symptoms - Go to Emergency Room

Signs of Cardiac Tamponade

• Severe shortness of breath that's getting worse
• Cannot lie flat without severe breathlessness
• Swelling in legs, ankles, or abdomen
• Extreme fatigue or weakness
• Lightheadedness when standing
• Neck vein distension

Signs Suggesting Heart Attack Instead

• Crushing chest pressure or heaviness
• Pain that doesn't change with position
• Nausea and vomiting with chest pain
• Sweating with chest discomfort
• Pain in left arm, jaw, or back

For Patients with Known Pericarditis

Contact Your Doctor If:

• Symptoms worsen: Despite treatment
• New symptoms develop: Swelling, severe fatigue
• Medication side effects: GI upset, rash, other concerns
• No improvement: After 1 week of treatment
• Fever develops: New fever during treatment

Signs of Recurrence

• Return of characteristic chest pain
• Pain with breathing or position changes
• New palpitations or irregular heartbeat
• Fatigue or exercise intolerance

What Information to Provide to Healthcare Providers

Symptom Details

• Pain characteristics: Location, quality, severity (1-10 scale)
• Timing: When symptoms started, duration
• Triggers: What makes pain better or worse
• Associated symptoms: Fever, shortness of breath, palpitations
• Activity level: How symptoms affect daily activities

Medical History

• Previous heart problems or procedures
• Recent illnesses, especially viral infections
• Current medications and recent changes
• Family history of heart disease
• Travel history or unusual exposures

Preparing for Your Appointment

• Symptom diary: Track pain patterns and triggers
• Medication list: All prescription and OTC medications
• Question list: Prepare questions about diagnosis and treatment
• Support person: Bring someone to help remember information
• Medical records: Previous cardiac tests or procedures

Follow-up Care

• Scheduled appointments: Keep all follow-up visits
• Medication compliance: Take medications as prescribed
• Activity modifications: Follow exercise restrictions
• Symptom monitoring: Watch for changes or recurrence
• Communication: Contact provider with concerns

Related Conditions

Pericarditis is associated with various cardiac and systemic conditions. Understanding these relationships helps in comprehensive diagnosis, treatment, and monitoring for complications.

Cardiac Complications

• Pericardial effusion - Fluid accumulation around heart
• Constrictive pericarditis - Chronic scarring limiting heart function
• Arrhythmias - Irregular heart rhythms
• Atrial fibrillation - Common arrhythmia in pericarditis

Underlying Autoimmune Conditions

• Systemic lupus erythematosus - Multisystem autoimmune disease
• Rheumatoid arthritis - Inflammatory joint disease
• Scleroderma - Systemic connective tissue disease
• Inflammatory bowel disease - Crohn's or ulcerative colitis
• Behçet's disease - Systemic vasculitis
• Sarcoidosis - Granulomatous inflammatory disease

Infectious Causes

• Viral infections - Coxsackievirus, EBV, CMV
• Tuberculosis - Important cause worldwide
• Bacterial infections - Purulent pericarditis
• COVID-19 - Emerging cause of pericarditis

Malignancy-Related

• Lung cancer - Direct extension or metastasis
• Breast cancer - Metastatic involvement
• Lymphoma - Mediastinal involvement
• Mesothelioma - Primary pericardial tumor

Post-Procedural Conditions

• Post-cardiac injury syndrome - After surgery or MI
• Dressler's syndrome - Late post-MI pericarditis
• Radiation pericarditis - From chest radiation therapy

Metabolic and Systemic Conditions

• Chronic kidney disease - Uremic pericarditis
• Hypothyroidism - Can cause pericardial effusion
• Gout - Uric acid crystal deposition

Differential Diagnoses

• Acute coronary syndrome - Heart attack or unstable angina
• Pulmonary embolism - Blood clot in lungs
• Aortic dissection - Tear in aorta wall
• Pneumonia - Lung infection
• Pleuritis - Inflammation of lung lining
• GERD - Acid reflux disease
• Panic disorder - Anxiety-related chest pain

Drug-Induced Conditions

• Drug-induced lupus - From hydralazine, procainamide
• Medication side effects - Various cardiotoxic drugs
• Bleeding complications - From blood thinners

Long-term Complications

• Recurrent pericarditis (15-30% of cases)
• Chronic pericardial disease
• Exercise intolerance
• Quality of life impairment
• Psychological effects (anxiety, depression)

Associated Syndromes

• Familial Mediterranean fever - Genetic autoinflammatory disease
• Periodic fever syndromes - Various hereditary conditions
• Mixed connective tissue disease - Overlap autoimmune features

Frequently Asked Questions

References

1. Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-64.
2. Imazio M, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011;155(7):409-14.
3. Imazio M, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-8.
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