Acute pericarditis
Acute pericarditis is inflammation of the pericardium, most often viral or idiopathic, presenting with pleuritic chest pain relieved by sitting forward, a pericardial friction rub, and diffuse ST elevation with PR depression. Treatment is an NSAID plus colchicine, and the main hazards are effusion, tamponade, and recurrence.
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What this article covers
- Overview
Definition: acute pericarditis is inflammation of the pericardium, presenting acutely with chest pain and often a small effusion.
- Epidemiology
Most cases are viral or idiopathic. A common cause of chest pain in young and middle-aged adults.
- Risk factors
Recent viral (often respiratory or gastrointestinal) infection.
- Pathophysiology
Pericardial inflammation: an inflamed, roughened pericardium produces the friction rub and pain.
- Clinical features
Sharp, pleuritic chest pain, worse supine and relieved by sitting forward, often radiating to the trapezius ridge.
- Differential diagnosis
Acute myocardial infarction: localized ST elevation with reciprocal changes, distinguished from pericarditis by territorial rather than diffuse ST elevation and a marked troponin rise (ST-elevation myocardial infarction (STEMI)).
- Diagnosis
Establish clinically by at least two of four criteria: pleuritic positional chest pain, a friction rub, characteristic ECG changes, and a new or worsening effusion: the diagnostic basis is meeting…
- Management
First-line, start anti-inflammatory therapy: An NSAID: ibuprofen 600 to 800 mg PO three times daily, or aspirin 750 to 1000 mg PO three times daily, for 1 to 2 weeks with a taper.
- Complications
Pericardial effusion and cardiac tamponade.
- Prognosis
Excellent for viral and idiopathic disease, usually self-limited.
- Prevention
Colchicine for 3 months to prevent recurrence.
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Related articles
- Pericardial effusion
Pericardial effusion is accumulation of fluid in the pericardial space, ranging from an incidental finding to life-threatening tamponade. Its hemodynamic effect depends on the rate of accumulation rather than volume alone, and management ranges from observation and treating the cause to pericardiocentesis for tamponade or large symptomatic effusions.
- Cardiac tamponade
Cardiac tamponade is life-threatening compression of the heart by a pericardial effusion, impairing diastolic filling and cardiac output. It presents with hypotension, distended neck veins, and pulsus paradoxus, is confirmed by echocardiography, and is treated by urgent pericardiocentesis; avoid vasodilators and aggressive diuresis.
- Constrictive pericarditis
Constrictive pericarditis is a rigid, often calcified pericardium that impairs diastolic filling, causing predominantly right-sided heart failure. It follows pericardial injury (post-surgical, tuberculous, radiation, or idiopathic), is distinguished from restrictive cardiomyopathy by hemodynamic and imaging features, and definitive treatment is pericardiectomy.
- ST-elevation myocardial infarction (STEMI)
ST-elevation myocardial infarction is acute transmural myocardial ischemia from complete coronary occlusion, diagnosed by ischemic symptoms with diagnostic ST-segment elevation and a rising troponin. It is a time-critical emergency in which immediate reperfusion, primary PCI within 90 minutes or fibrinolysis when PCI is unavailable, plus antiplatelet and anticoagulant therapy, determines survival.
- Myocarditis
Myocarditis is inflammation of the myocardium, most often postviral or immune-mediated, presenting across a spectrum from a mild chest-pain syndrome mimicking myocardial infarction to fulminant heart failure and arrhythmia. Diagnosis relies on cardiac MRI (or biopsy for severe or refractory cases), and treatment is supportive heart-failure care, with cause-specific immunosuppression for giant cell, checkpoint-inhibitor, and autoimmune myocarditis.
- Aortic dissection
Aortic dissection is a tear in the aortic intima allowing blood to split the media, creating a false lumen, and is a surgical emergency. Type A (ascending) dissection needs emergency surgery, while type B (descending) is usually managed medically with rapid heart-rate and blood-pressure control; the priority is impulse control with a beta-blocker first.