Acute pericarditis is the inflammation of the pericardium, the fibrous sac surrounding the heart. It presents with chest pain, pericardial friction rub, and characteristic ECG changes. Early recognition is crucial to prevent complications such as cardiac tamponade and constrictive pericarditis.
2. Causes of Acute Pericarditis
Acute pericarditis can be idiopathic or caused by infections, autoimmune diseases, malignancies, or metabolic disorders.
(A) Infectious Causes
- Viral (most common): Coxsackievirus, influenza, echovirus, HIV
- Bacterial: Tuberculosis, Staphylococcus, Streptococcus pneumoniae
- Fungal: Histoplasmosis, Aspergillus (rare)
(B) Non-Infectious Causes
- Post-myocardial infarction:
- Early pericarditis (1-3 days post-MI)
- Dressler’s syndrome (autoimmune, weeks post-MI)
- Autoimmune Diseases: SLE, rheumatoid arthritis, scleroderma
- Uremic Pericarditis: Chronic kidney disease, dialysis patients
- Malignancy: Lung cancer, breast cancer, lymphoma, leukemia
- Radiation Therapy: Chest irradiation
- Drugs: Hydralazine, isoniazid, procainamide
- Trauma: Blunt chest trauma, post-cardiac surgery
3. Clinical Features
| Symptom/Sign | Clinical Features |
|---|---|
| Chest Pain | Sharp, pleuritic, worsens with supine position, relieved by sitting forward |
| Pericardial Friction Rub | High-pitched, scratchy sound heard best at the left sternal border |
| ECG Changes | Diffuse ST elevation, PR depression |
| Fever | Low-grade fever in viral pericarditis |
| Dyspnea | Due to pericardial effusion or tamponade |
🔹 Pleuritic chest pain + pericardial rub + ECG changes = Classic Triad of Pericarditis
4. Diagnosis of Acute Pericarditis
(A) Diagnostic Criteria (NICE & ESC Guidelines)
Diagnosis requires at least 2 of 4 criteria:
- Typical chest pain (sharp, pleuritic, improves with sitting forward)
- Pericardial friction rub
- ECG changes (Diffuse ST elevation, PR depression)
- Pericardial effusion (Echocardiography)
(B) ECG Changes in Acute Pericarditis
| Stage | ECG Findings |
|---|---|
| Stage 1 | Diffuse ST elevation, PR depression |
| Stage 2 | ST normalization |
| Stage 3 | T wave inversion |
| Stage 4 | Normalization of T waves |
(C) Laboratory & Imaging Workup
| Test | Purpose |
|---|---|
| ESR/CRP | Inflammatory markers (elevated) |
| Cardiac Troponins | Mildly elevated in myopericarditis |
| Echocardiogram | Detects pericardial effusion, tamponade |
| CXR | May show cardiomegaly in large effusion |
| Pericardiocentesis | If purulent or neoplastic pericarditis suspected |
5. Management of Acute Pericarditis
(A) First-Line Treatment (Idiopathic/Viral Pericarditis)
| Drug | Indication | Dose & Duration |
|---|---|---|
| NSAIDs (Ibuprofen) | Pain relief, inflammation reduction | 600-800 mg TDS for 1-2 weeks |
| Aspirin | Post-MI pericarditis | 650-1000 mg TDS for 1-2 weeks |
| Colchicine | Reduces recurrence risk | 0.5 mg BD for 3 months |
| Gastric Protection (PPI) | Prevents GI irritation from NSAIDs | Omeprazole 20 mg OD |
🔹 Colchicine + NSAIDs/Aspirin is the preferred treatment
🔹 Avoid corticosteroids unless NSAIDs are contraindicated
(B) Specific Management in Secondary Pericarditis
| Cause | Management |
|---|---|
| Bacterial Pericarditis | IV antibiotics, urgent pericardial drainage |
| Tuberculous Pericarditis | Anti-TB therapy (RIPE regimen) |
| Uremic Pericarditis | Intensified dialysis |
| Malignant Pericarditis | Pericardiocentesis, chemotherapy |
6. Complications of Acute Pericarditis
🚨 Pericardial Effusion → Fluid accumulation in the pericardial sac
🚨 Cardiac Tamponade → Compression of the heart, requiring emergency pericardiocentesis
🚨 Constrictive Pericarditis → Chronic fibrosis leading to diastolic dysfunction
(A) Signs of Cardiac Tamponade (Beck’s Triad)
- Hypotension
- Distended neck veins (JVP elevation)
- Muffled heart sounds
Other signs: Pulsus paradoxus (BP drop >10 mmHg on inspiration), Electrical alternans on ECG
7. Key Takeaways
✅ Acute pericarditis presents with pleuritic chest pain, pericardial friction rub, and diffuse ST elevation.
✅ Viral infections and idiopathic causes are most common.
✅ NSAIDs + colchicine are first-line therapy; steroids are used in refractory cases.
✅ Complications include cardiac tamponade (Beck’s triad) and constrictive pericarditis.
✅ Urgent pericardiocentesis is needed for cardiac tamponade.
Further Reading
- NHS Overview of Pericarditis: NHS UK
- European Society of Cardiology (ESC) Guidelines: ESC Guidelines
