Acute Pericarditis
Acute pericarditis is an inflammation of the sac surrounding the heart, causing sharp chest pain that gets worse with deep breathing but feels better when sitting up and leaning forward.
Emergency Management: Cardiac Tamponade causing hemodynamic collapse requires emergent echocardiography-guided Pericardiocentesis to drain the fluid and restore cardiac output.
An acute inflammation of the pericardium, the double-walled fibroserous sac enclosing the heart. The core pathology involves inflammation-induced exudation of fluid and fibrin into the pericardial space, often irritating the adjacent diaphragmatic pleura and epicardium.
Detailed Overview
Acute pericarditis is most commonly idiopathic or viral in origin. The inflammation causes classic pleuritic chest pain that improves when leaning forward. A localized inflammatory exudate creates a high-pitched friction rub. While usually a benign, self-limited condition, the inflammation can lead to an accumulation of fluid (pericardial effusion). If this fluid accumulates rapidly, it can restrict cardiac filling, leading to life-threatening cardiac tamponade. Recurrence is a common complication.
Epidemiology & Demographics
Accounts for roughly 5% of non-ischemic chest pain presentations to the emergency department. Most commonly affects young to middle-aged males (20-50 years old).
Etiological Mechanism
Idiopathic (presumed viral) accounts for >80% of cases in developed nations. Coxsackievirus, Echovirus, and Adenovirus are common culprits. In developing nations, Tuberculosis is a leading cause.
Primary Causes
Viral infection (Coxsackievirus, Adenovirus, COVID-19)
Post-Myocardial Infarction (Dressler syndrome)
Uremia (severe renal failure)
Systemic autoimmune diseases (Lupus, Rheumatoid Arthritis)
Malignancy (lung, breast, lymphoma)
An infectious or immune-mediated trigger causes acute inflammation of the visceral and parietal pericardium. This leads to local vasodilation, increased capillary permeability, and infiltration of polymorphonuclear leukocytes. A fibrinous or serofibrinous exudate coats the pericardial surfaces. The friction between these roughened surfaces during the cardiac cycle causes the pathognomonic rub and intense pain. Because the central diaphragm and lower pericardium share innervation via the phrenic nerve, pain often radiates to the shoulder ridge. Extension of inflammation to the superficial myocardium causes the classic ECG changes.
Diagnostic Criteria & Guidelines
Requires at least 2 of 4 criteria: 1) Typical pleuritic chest pain. 2) Pericardial friction rub. 3) Widespread ST-elevation or PR depression on ECG. 4) New or worsening pericardial effusion on echocardiogram.
High-dose NSAIDs (Ibuprofen 600-800 mg PO TID for 1-2 weeks) PLUS Colchicine (0.5 mg PO once or twice daily based on weight, for 3 months). Colchicine significantly reduces the risk of recurrence. Gastric protection with a PPI (Pantoprazole 40 mg daily) is recommended.
Second-Line & Adjunctive Therapy
If NSAIDs/Colchicine are contraindicated or ineffective: Systemic Corticosteroids (Prednisone 0.2-0.5 mg/kg/day). Note: Steroids should be avoided as first-line therapy if possible because they increase the risk of recurrent pericarditis upon tapering.
Surgical & Procedural Management
Pericardiocentesis is indicated if cardiac tamponade develops, or for moderate-to-large effusions suspected to be bacterial or neoplastic. Pericardial window for recurrent large effusions. Pericardiectomy for constrictive pericarditis.
Patient Counseling & Advice
Warn the patient that pericarditis can recur in up to 30% of cases. Emphasize that taking Colchicine exactly as prescribed for the full 3-month course is the best way to prevent recurrence. Advise to seek immediate care if symptoms of lightheadedness or severe shortness of breath occur.
Follow-Up & Monitoring Schedule
Weekly follow-up with CRP measurement to guide the tapering of NSAIDs. Do not start tapering NSAIDs until the patient is symptom-free and CRP is strictly normal.
Preventive Strategies
The only established secondary prevention is adherence to Colchicine therapy.
Excellent for acute viral/idiopathic pericarditis. Most recover completely within weeks. Recurrence occurs in 15-30% of patients not treated with Colchicine.