Pericarditis

What Is Pericarditis?

Pericarditis is inflammation of the pericardium, the thin, two-layered, fluid-filled sac that surrounds and protects the heart. Normally, a small amount of lubricating fluid sits between these layers, allowing the heart to move smoothly as it beats.

When the pericardium becomes inflamed, the layers can rub against each other, causing chest pain and irritation around the heart.

Types of Pericarditis

Pericarditis is classified based on how long symptoms last:

• Acute pericarditis: sudden onset, lasting less than 3 weeks

• Subacute pericarditis: develops gradually, lasting 3 weeks to 3 months

• Chronic pericarditis: persists longer than 3 months

• Recurrent pericarditis: symptoms return after initial recovery

It can affect people of any age but is most common in adults aged 20–50, with men affected more frequently than women.

Symptoms of Pericarditis

The most characteristic symptom is sharp, stabbing chest pain, typically:

• Located behind the breastbone or on the left side of the chest

• Worse when lying down, breathing deeply, coughing, or swallowing

• Improved when sitting up and leaning forward

Other common symptoms include:

• Low-grade fever

• Shortness of breath (especially when lying flat)

• Rapid or irregular heartbeat (palpitations)

• Fatigue and weakness

• Dry cough

• Swelling in the legs or abdomen (in more severe cases)

Causes of Pericarditis

Pericarditis has many possible causes. In many cases, the exact cause is not identified (idiopathic), especially when viral.

Common Causes

Viral infections (most common):

• Coxsackievirus

• Echovirus

• Influenza

• COVID-19

Bacterial infections:

• More common after surgery, trauma, or in immunocompromised individuals

Autoimmune and inflammatory diseases:

• Lupus

• Rheumatoid arthritis

• Scleroderma

• Sjögren’s syndrome

Post-cardiac injury:

• After a heart attack (early or Dressler syndrome)

• After heart surgery or procedures

Other causes:

• Chest trauma or injury

• Kidney failure (uremic pericarditis)

• Cancer involving the pericardium

• Radiation therapy to the chest

• Certain medications (e.g., hydralazine, procainamide, isoniazid, phenytoin)

• Severe infections (fungal or parasitic, rare)

How Pericarditis Is Diagnosed

Diagnosis combines clinical symptoms, physical exam, and testing.

Physical Exam

Doctors may hear a pericardial friction rub, a scratchy sound caused by inflamed layers rubbing together.

Key Tests

• Electrocardiogram (ECG):
  Shows characteristic changes such as widespread ST elevation and PR depression

• Echocardiogram:
  Detects fluid around the heart (pericardial effusion) and evaluates heart function

• Chest X-ray:
  May show an enlarged heart if fluid is present

• Blood tests:

  • Elevated inflammatory markers (CRP, ESR)

  • Increased white blood cell count

  • Mild troponin/troponin T, High Sensitivity elevation (if myocardium involved — myopericarditis)

• Cardiac CT or MRI:
  Used for detailed imaging, detecting thickening, inflammation, or complications

Treatment for Pericarditis

Treatment depends on the cause and severity.

First-Line Treatment

• NSAIDs (e.g., ibuprofen, indomethacin): reduce inflammation and pain

• Colchicine: reduces symptoms and significantly lowers recurrence risk

Second-Line Treatment

• Corticosteroids (e.g., prednisone):
  Used when NSAIDs/colchicine fail or in autoimmune cases (higher recurrence risk)

Additional Management

• Rest and avoidance of strenuous activity (typically for at least 3 months)

• Treat underlying cause when identified:

  • Antibiotics for bacterial infection

  • Immunosuppressive therapy for autoimmune disease

  • Discontinuation of offending medications

Severe or Complicated Cases

• Pericardiocentesis: drainage of fluid in cardiac tamponade

• Pericardiectomy: surgical removal of the pericardium in chronic constrictive pericarditis

Complications of Pericarditis

Most cases are mild, but complications can occur:

• Pericardial effusion: fluid buildup around the heart

• Cardiac tamponade: life-threatening compression of the heart

• Constrictive pericarditis: thickened, scarred pericardium limiting heart function

• Myopericarditis: inflammation involving both the pericardium and heart muscle

Prognosis and Recovery

The prognosis for acute pericarditis is generally excellent:

• Symptoms usually improve within days to weeks

• Most patients recover completely

However:

• 15–30% of patients experience recurrence

• Recurrence typically occurs within 18 months

• Some cases become chronic and require long-term management

With appropriate treatment and follow-up, most individuals return to normal activities.

Key Takeaway

Pericarditis is inflammation of the protective sac around the heart that commonly causes sharp chest pain, especially when lying down or breathing deeply. Most cases are caused by viral infections and resolve with anti-inflammatory treatment, but accurate diagnosis is important to rule out complications like cardiac tamponade.