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Pericarditis

Clinical Subject Page

Pericarditis

Also called

Inflammation of the pericardium

ICD-10

I30.9

Specialty

Cardiology

Onset

Acute or Chronic

Reviewed

June 2026

On This Page

Overview

Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart). It may be: Acute: lasts from days to weeks Chronic: persists for more than 3 months Acute pericarditis is most commonly caused by a viral infection, although many other conditions can trigger inflammation of the pericardium.

Typical features include: Low-grade fever Pleuritic chest pain (worse with deep inspiration) Pericardial friction rub on auscultation

Etiology & Risk Factors

Etiology

Common causes include:

1. Idiopathic

  • No identifiable cause (many are presumed viral)

2. Infectious

  • Viral (most common): e.g., Coxsackie B virus
  • Bacterial (e.g., Staphylococcus, Streptococcus, Mycobacterium tuberculosis)
  • Fungal infections
  • Toxoplasmosis

3. Cardiac causes

  • Myocardial infarction
    • Early post-infarction fibrinous pericarditis (within 1–3 days)
    • Dressler syndrome (weeks to months after MI)

4. Postoperative/Traumatic

  • Postpericardiotomy syndrome
  • Blunt or penetrating chest trauma

5. Metabolic

  • Uremia due to acute or chronic renal failure

6. Radiation-induced

7. Malignancy

  • e.g., Hodgkin lymphoma

8. Autoimmune diseases

  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Scleroderma

9. Rare cause

  • Following mRNA COVID-19 vaccination (rare; risk highest in males aged 12–24 years, and the risk is higher after SARS-CoV-2 infection than after vaccination)

Risk Factors

Based on the reported causes, factors associated with an increased risk include:

  • Viral or other infectious illnesses
  • Recent myocardial infarction
  • Recent cardiac surgery or chest trauma
  • Acute or chronic kidney failure (uremia)
  • Previous chest radiation therapy
  • Autoimmune connective tissue diseases
  • Malignancy
  • Rarely, recent mRNA COVID-19 vaccination (especially in young males)

Pathophysiology

Pericarditis develops when the pericardium becomes inflamed due to infection or another inflammatory trigger.

The inflammatory process can:

  • Cause inflammation of the pericardial layers.
  • Produce chest pain because the inflamed pericardial surfaces rub against each other.
  • Lead to accumulation of fluid in the pericardial space (pericardial effusion) in some patients.

If significant pericardial fluid accumulates, it may progress to cardiac tamponade, in which:

  1. Pericardial fluid increases pressure within the pericardial sac.
  2. The heart, especially the thin-walled right ventricle, is compressed.
  3. Ventricular filling during diastole decreases.
  4. Stroke volume and cardiac output decrease.
  5. Venous congestion develops, potentially causing life-threatening hemodynamic compromise.

Clinical Presentation

Pericarditis · Clinical Presentation

Acute Pericarditis
Inflammation of the pericardium - most commonly viral. Pleuritic chest pain and friction rub. Diagnosis requires ≥2 of 4 ESC criteria.
Constrictive Pericarditis
Chronic fibrous thickening - restricts diastolic filling. Presents as right-sided heart failure with unique haemodynamic signs.
Effusive-Constrictive
Combined features of constriction and effusion. Ranges from asymptomatic to cardiac tamponade depending on size and rate of accumulation.
Acute Pericarditis
Symptoms
Sharp, pleuritic chest pain - most common; acute, retrosternal
Worsens with deep inspiration, coughing, swallowing
Improves sitting up and leaning forward
Radiates to neck & left shoulder
Low-grade intermittent fever
Shortness of breath (dyspnea)
Rapid breathing (tachypnea)
Dry, nonproductive cough
Flu-like symptoms - especially with viral aetiology
Physical Examination
Pericardial friction rub Classic finding
High-pitched, scratching - "walking on fresh snow"
Best at left sternal border
Loudest during expiration, patient leaning forward
Evanescent - may disappear and reappear
If pericardial effusion develops:
Faint, distant heart sounds
Ewart sign - dullness at left lung base
ESC 2015 - Diagnosis requires ≥2
Pleuritic chest pain
Pericardial friction rub
New widespread ST elevation or PR depression
New or worsening pericardial effusion on echo
Chronic (Constrictive) Pericarditis
Symptoms of Fluid Overload (Backward HF)
Jugular venous distention (JVD)
Elevated JVP
Peripheral pitting oedema
Generalised oedema (anasarca)
Ascites with abdominal discomfort
Hepatomegaly and painful hepatic congestion
Symptoms of Low Cardiac Output (Forward HF)
Fatigue and exercise intolerance
Dyspnea on exertion
Tachycardia (compensatory)
Physical Examination
Pericardial knock Pathognomonic
Early diastolic sound - abrupt cessation of ventricular filling
Higher pitched than S3; occurs earlier
Best heard at left sternal border
Kussmaul sign Classic
Paradoxical rise in JVP during inspiration
Opposite of normal - JVP normally falls on inspiration
Also seen in RV infarction, restrictive CM
Pulsus paradoxus
Less prominent than in cardiac tamponade
Drop in systolic BP >10 mmHg on inspiration
Effusive-Constrictive Pericarditis
Clinical features
Features of constrictive pericarditis (pericardial knock, Kussmaul sign)
Features of pericardial effusion (distant heart sounds, Ewart sign)
A combination of both simultaneously
Presentation depends on effusion
Asymptomatic - small or slowly accumulating effusion
Cardiac tamponade - large or rapid accumulation
Beck's Triad of Cardiac Tamponade
Hypotension
Muffled heart sounds
Elevated JVP / JVD
Dullness at left lung base (Ewart sign) - compression by large effusion
Key Clinical Features to Remember
🗡️
Sharp pleuritic chest pain
Most common presenting symptom - acute, retrosternal, worsens with breathing
🪑
Positional relief
Pain relieved sitting up and leaning forward - distinguishes pericarditis from MI
🩺
Pericardial friction rub
Pathognomonic scratching at left sternal border - evanescent
🌡️
Low-grade fever
Intermittent; high fever raises concern for bacterial cause
💨
Dyspnea
From pleuritic pain or from effusion compressing adjacent lung
⚠️
Complication signs
Muffled sounds + hypotension + JVD = tamponade. Knock + Kussmaul = constriction.

History Taking

1. Chest Pain

  • Where is the pain?
  • Is it sharp or stabbing?
  • Does it worsen with deep breathing or coughing?
  • Does it improve when sitting up or leaning forward?
  • Does it radiate to the neck or left shoulder?

2. Associated Symptoms

  • Do you have fever?
  • Are you short of breath?
  • Do you have a dry cough?
  • Have you noticed palpitations or fainting?

3. Possible Causes

  • Have you had a recent viral illness or fever?
  • Have you had a recent heart attack, heart surgery, or chest injury?
  • Do you have kidney disease, autoimmune disease, or cancer?

4. Red Flags

  • Is your fever above 38°C?
  • Is your shortness of breath getting worse?
  • Have you ever fainted?

Investigations

1. Electrocardiogram (ECG) – First-line

Typical findings:

  • Diffuse ST-segment elevation
  • PR-segment depression
  • Later: T-wave inversion

2. Echocardiography (TTE) – First-line

  • Detects pericardial effusion
  • Assesses for cardiac tamponade
  • May be normal in uncomplicated pericarditis

3. Blood Tests

  • CBC: leukocytosis
  • CRP and ESR: elevated inflammatory markers
  • Troponin I/T: may be mildly elevated (higher levels suggest associated myocarditis)
  • Creatine kinase (CK): may be elevated

4. Chest X-ray

  • Usually normal
  • May show an enlarged cardiac silhouette if there is a large pericardial effusion

5. CT Scan or Cardiac MRI (if diagnosis is uncertain)

  • Detects pericardial inflammation
  • Shows pericardial thickening or effusion

6. Pericardiocentesis (if indicated)

Indications:

  • Cardiac tamponade
  • Large pericardial effusion
  • Suspected bacterial or malignant pericarditis

Pericardial fluid analysis:

  • Gram stain and culture
  • Acid-fast bacilli (TB) testing
  • PCR
  • Cytology

Additional Tests (Based on Suspected Cause)

  • Kidney function: BUN, creatinine, electrolytes (uremia)
  • Blood cultures (suspected bacterial infection)
  • ANA and rheumatoid factor (autoimmune disease)
  • TB testing and HIV test (suspected tuberculous pericarditis)

Diagnosis

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Related Topics
FeatureAcute PericarditisChronic Pericarditis (Constrictive)
Diagnostic basisDiagnosis requires ≥ 2 of 4 criteriaDiagnosis is based primarily on characteristic imaging findings
Clinical findingsCharacteristic pleuritic chest pain and/or pericardial friction rubSymptoms and signs of constrictive physiology (assessed with imaging)
ECGDiffuse ST-segment elevation, PR-segment depressionMay show low QRS voltage, generalized flat/inverted T waves; atrial fibrillation may occur
Echocardiography (TTE)Detects new/worsening pericardial effusion; may be normalIncreased pericardial thickness, abnormal ventricular filling, respiratory variation in filling
CT / Cardiac MRIUsed if diagnosis is uncertain; shows pericardial inflammation, thickening, or effusionShows pericardial thickening (>2 mm) and calcification; confirms constrictive disease
Laboratory testsCBC, CRP, ESR, Troponin I/TSimilar tests as acute; BNP may help differentiate from restrictive cardiomyopathy, LFTs may be abnormal
Additional testsPericardiocentesis if tamponade, large effusion, or suspected bacterial/malignant causeCardiac catheterization if noninvasive tests are inconclusive

Management

ManagementAcute PericarditisChronic Pericarditis (Constrictive)
First-line treatmentNSAIDs (aspirin, ibuprofen, or indomethacin)Consider anti-inflammatory therapy if transient constrictive pericarditis
Adjunct therapyColchicine with NSAIDs or as monotherapyTreat heart failure (e.g., diuretics, sodium restriction)
CorticosteroidsPrednisone only in severe cases or when caused by uremia, connective tissue disease, or autoreactivityMay be considered if inflammation is present
Treat underlying causeAntibiotics (bacterial), TB therapy, immunosuppressants (autoimmune), dialysis (uremia)Treat the underlying cause whenever identified
ActivityRestrict physical activity until symptoms and inflammatory markers resolveActivity according to heart failure symptoms
Surgical treatmentPericardiocentesis for cardiac tamponade or large pericardial effusionPericardiectomy for persistent symptomatic constrictive or effusive-constrictive pericarditis
Hospital admissionRequired for poor prognosis (e.g., fever >38°C, large effusion, tamponade, elevated troponin, immunosuppression, anticoagulant therapy, recurrent disease, or failure to respond to NSAIDs)Consider admission if heart failure symptoms are present or further evaluation is required

Complications

ComplicationDescription
Cardiac tamponadeAccumulation of pericardial fluid causing compression of the heart, impaired ventricular filling, and reduced cardiac output. This is a medical emergency.
Constrictive pericarditisChronic scarring and thickening of the pericardium that restricts ventricular filling, leading to symptoms of right-sided heart failure.

Prognosis

ConditionPrognosis
Acute PericarditisUsually self-limited and resolves within days to weeks with appropriate anti-inflammatory treatment (NSAIDs ± colchicine). Most patients without poor prognostic features can be managed as outpatients.
Chronic PericarditisDefined as inflammation lasting > 3 months. Chronic disease is uncommon (about 2% of acute cases) and may progress to constrictive or effusive-constrictive pericarditis, which can require pericardiectomy.

Poor Prognostic Features (Acute Pericarditis)

  • Fever > 38°C
  • Subacute onset
  • Large pericardial effusion
  • Elevated troponin
  • Immunosuppression
  • Anticoagulant therapy
  • Recurrent pericarditis
  • Signs of hemodynamic compromise (e.g., hypotension, jugular venous distention)
  • No response to NSAIDs after 1 week

Key Points / Clinical Pearls

Key Points / Clinical Pearls

  • Acute pericarditis is most commonly caused by a viral infection.
  • Classic chest pain is sharp, pleuritic, worsens with inspiration, and improves when sitting up and leaning forward.
  • Pericardial friction rub is the characteristic physical examination finding.
  • Diagnosis of acute pericarditis requires ≥ 2 of the following:
    • Characteristic chest pain
    • Pericardial friction rub
    • Typical ECG changes (diffuse ST-segment elevation)
    • New or worsening pericardial effusion
  • ECG typically shows diffuse ST-segment elevation and PR-segment depression.
  • Echocardiography (TTE) is the first-line imaging study to detect pericardial effusion and assess for cardiac tamponade.
  • NSAIDs plus colchicine are the mainstay of treatment for most patients with acute pericarditis.
  • Cardiac tamponade is the most serious acute complication and requires urgent pericardiocentesis.
  • Constrictive pericarditis is the major chronic complication and may require pericardiectomy.
  • Poor prognostic features include fever > 38°C, large pericardial effusion, elevated troponin, recurrent disease, immunosuppression, anticoagulant therapy, and hemodynamic compromise.
  • Dababneh E, Siddique MS. National Center for Biotechnology Information (NIH). Pericarditis, StatPearls.
  • Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the Management of Myocarditis and Pericarditis. Eur Heart J. 2025;46:3952-4041. doi: 10.1093/eurheartj/ehaf192.
  • Imazio M, Brucato A, Cemin R, et al; ICAP Investigators. A Randomized Trial of Colchicine for Acute Pericarditis. N Engl J Med. 2013;369:1522-1528. PMID: 23992557.
  • MedlinePlus, National Library of Medicine (NIH). Pericarditis: Medical Encyclopedia.
  • Klein AL, Imazio M, Cremer P, et al. Phase 3 Trial of Interleukin-1 Trap Rilonacept in Recurrent Pericarditis. N Engl J Med. 2021;384:31-41. PMID: 33200890.