Pericarditis: Symptoms, Causes & Complete Treatment Guide

What Is Pericarditis?

Pericarditis is inflammation of the pericardium, the thin double-layered sac surrounding the heart. The pericardium normally contains a small amount of fluid that lubricates the heart's movement. When inflamed, the pericardial layers rub against each other, causing characteristic sharp chest pain.

The pericardium serves several important functions in the body. It holds the heart in position within the chest, prevents the heart from over-expanding when blood volume increases, and protects the heart from infection spreading from nearby organs such as the lungs. The pericardium consists of two layers: the visceral pericardium (attached directly to the heart surface) and the parietal pericardium (the outer layer). Between these layers is the pericardial space, which normally contains 15-50 milliliters of fluid.

When the pericardium becomes inflamed, these layers can become rough and irritated, creating friction with each heartbeat. This inflammation can also cause excess fluid to accumulate in the pericardial space, a condition called pericardial effusion. In severe cases, this fluid accumulation can compress the heart and impair its ability to pump blood effectively, a life-threatening condition called cardiac tamponade.

Pericarditis is classified based on its duration and pattern of occurrence. Acute pericarditis refers to the initial episode lasting less than 4-6 weeks. Incessant pericarditis describes symptoms lasting longer than 4-6 weeks but less than 3 months without a symptom-free interval. Recurrent pericarditis occurs when symptoms return after an initial episode with at least a 4-6 week symptom-free interval. Chronic pericarditis persists for longer than 3 months.

Who Gets Pericarditis?

Pericarditis can affect anyone, but certain patterns have been observed in research studies. The condition is more common in men than women, particularly in younger age groups. The peak incidence occurs in adults aged 16-65 years. According to epidemiological studies, pericarditis accounts for approximately 5% of emergency department visits for chest pain and has an annual incidence of about 27.7 cases per 100,000 population in developed countries.

While pericarditis can occur at any age, the underlying causes may differ across age groups. In young adults, viral infections are the most common trigger. In older adults, pericarditis may more often be associated with underlying conditions such as malignancy, kidney disease, or autoimmune disorders. Understanding these patterns helps healthcare providers identify potential causes and tailor treatment approaches accordingly.

What Are the Symptoms of Pericarditis?

The main symptom of pericarditis is sharp, stabbing chest pain that characteristically worsens when lying down or taking deep breaths and improves when sitting up and leaning forward. Other symptoms include fever, fatigue, shortness of breath, and a dry cough. A distinctive pericardial friction rub may be heard by a doctor using a stethoscope.

Chest pain is the predominant symptom in pericarditis, occurring in more than 85-90% of cases. This pain has several distinctive characteristics that help differentiate it from other causes of chest pain, particularly heart attack. The pain of pericarditis is typically described as sharp, stabbing, or piercing rather than the pressure or squeezing sensation common in heart attacks. It is usually located in the center of the chest (retrosternal) or the left chest but may radiate to the neck, shoulders, arms, or back.

The most characteristic feature of pericarditis pain is its positional nature. Patients typically report that lying flat significantly worsens the pain, while sitting up and leaning forward provides relief. This occurs because when lying flat, the inflamed pericardial layers are in closer contact, creating more friction. Leaning forward separates these layers somewhat, reducing irritation. The pain also typically worsens with deep breathing, coughing, or swallowing because these actions move the pericardium against the heart.

Associated Symptoms

Beyond chest pain, pericarditis often presents with additional symptoms that reflect the underlying inflammation. Fever is common, particularly in infectious causes, and typically ranges from low-grade (37.5-38°C/99.5-100.4°F) to moderate. High fever (above 38°C/100.4°F) may suggest bacterial infection or a more severe inflammatory process requiring prompt medical evaluation.

Fatigue and general malaise frequently accompany pericarditis. Patients often report feeling tired and unwell, similar to having a flu-like illness. This is particularly common when pericarditis follows a viral respiratory infection, as the body is simultaneously fighting the initial infection and dealing with cardiac inflammation.

Shortness of breath (dyspnea) can occur in pericarditis and may have several causes. Mild shortness of breath may result from pain limiting deep breathing. More significant dyspnea, especially when lying flat (orthopnea), can indicate the development of a pericardial effusion that is compressing the heart or lungs. Progressive shortness of breath warrants prompt medical evaluation.

Palpitations (awareness of heartbeat) and mild tachycardia (rapid heart rate) are common and typically result from the body's response to pain and inflammation. However, persistent or severe palpitations should be evaluated as they may indicate arrhythmias.

What Causes Pericarditis?

The most common cause of pericarditis is viral infection (80-85% of cases in developed countries), often following a respiratory illness. Other causes include bacterial infections, autoimmune diseases like lupus, kidney failure, heart attack, chest trauma, cancer, radiation therapy, and certain medications. In many cases, no specific cause is identified (idiopathic pericarditis).

Understanding the underlying cause of pericarditis is important because it guides treatment decisions and helps predict outcomes. However, in clinical practice, identifying the specific cause can be challenging. Studies suggest that in up to 80-90% of cases in developed countries, no specific cause is identified despite investigation, and these cases are presumed to be viral or classified as idiopathic (unknown cause).

Infectious Causes

Viral infections are the most common identified cause of acute pericarditis in developed countries. Many viruses can cause pericarditis, including enteroviruses (particularly Coxsackievirus), adenoviruses, herpesviruses (including Epstein-Barr virus and cytomegalovirus), influenza viruses, and more recently, SARS-CoV-2 (the virus causing COVID-19). Patients often report a recent upper respiratory infection, flu-like illness, or gastrointestinal illness preceding the onset of pericarditis symptoms.

Bacterial infections cause a more serious form called purulent pericarditis, which is fortunately rare in the modern antibiotic era. Bacterial pericarditis typically occurs as a complication of another infection (such as pneumonia), following heart surgery, or in immunocompromised patients. Common bacterial causes include Staphylococcus, Streptococcus, and Gram-negative organisms. Bacterial pericarditis requires urgent treatment with antibiotics and often surgical drainage.

Tuberculosis (TB) remains an important cause of pericarditis globally, particularly in developing countries and in people with HIV infection. TB pericarditis tends to have a more gradual onset and is more likely to progress to constrictive pericarditis if not properly treated.

Non-Infectious Causes

Autoimmune and inflammatory conditions can cause pericarditis as part of their systemic inflammation. Systemic lupus erythematosus (SLE) is one of the most common autoimmune causes, with pericarditis occurring in up to 25% of lupus patients at some point. Other autoimmune conditions associated with pericarditis include rheumatoid arthritis, scleroderma, Sjögren's syndrome, and inflammatory bowel disease.

Post-cardiac injury syndromes represent an important category of pericarditis. Post-myocardial infarction pericarditis can occur in two forms: early pericarditis (within days of a heart attack, due to direct inflammation of the pericardium adjacent to the damaged heart muscle) and Dressler syndrome (occurring 1-8 weeks after heart attack, believed to be an autoimmune reaction). Similar syndromes can occur after heart surgery (postpericardiotomy syndrome) or chest trauma.

Kidney failure (uremia) can cause uremic pericarditis, particularly in patients with advanced chronic kidney disease who are not yet on dialysis or who are inadequately dialyzed. This type of pericarditis responds to intensification of dialysis rather than anti-inflammatory medications.

Malignancy can cause pericarditis either through direct tumor invasion of the pericardium or as a paraneoplastic phenomenon. Cancers most commonly associated with pericardial involvement include lung cancer, breast cancer, lymphoma, and leukemia. Radiation therapy to the chest, often used to treat these cancers, can also cause radiation-induced pericarditis, either acutely or years after treatment.

Medications occasionally cause drug-induced pericarditis. Examples include hydralazine, procainamide, isoniazid, phenytoin, and certain biological therapies. Drug-induced pericarditis typically resolves after stopping the offending medication.

How Is Pericarditis Diagnosed?

Pericarditis is diagnosed based on the presence of at least 2 of 4 criteria: characteristic chest pain, pericardial friction rub on examination, typical ECG changes (diffuse ST elevation or PR depression), and new or worsening pericardial effusion on echocardiogram. Blood tests typically show elevated inflammatory markers (CRP, ESR) and may show mildly elevated cardiac enzymes.

The diagnosis of acute pericarditis is primarily clinical, based on a combination of symptoms, physical examination findings, and supportive test results. According to the European Society of Cardiology guidelines, the diagnosis requires at least two of the following four criteria to be present:

1. Pericarditic chest pain: Sharp, pleuritic pain that is worse lying down and improved leaning forward
2. Pericardial friction rub: The characteristic scratching sound heard on auscultation
3. ECG changes: New widespread ST-segment elevation or PR depression
4. Pericardial effusion: New or worsening fluid accumulation seen on echocardiogram

Electrocardiogram (ECG)

The ECG is one of the most useful tests in diagnosing pericarditis and helps distinguish it from heart attack. Classic ECG changes in pericarditis occur in stages. In the acute phase, diffuse ST-segment elevation is seen in most leads (unlike heart attack, where ST elevation is localized to specific leads corresponding to the affected coronary artery). PR-segment depression is another characteristic finding. Over days to weeks, the ECG evolves through stages of T-wave flattening, T-wave inversion, and eventually return to normal.

Echocardiogram

Echocardiography (ultrasound of the heart) is essential in evaluating pericarditis. It can detect pericardial effusion, even small amounts that might not cause symptoms. More importantly, it can identify signs of cardiac tamponade (compression of the heart by fluid) and assess overall heart function. Not all patients with pericarditis develop pericardial effusion, so a normal echocardiogram does not rule out the diagnosis.

Blood Tests

Laboratory tests support the diagnosis and help assess severity. Inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are typically elevated and are useful for monitoring treatment response. Cardiac troponin, a marker of heart muscle damage, may be mildly elevated in up to one-third of patients with pericarditis, indicating some involvement of the underlying heart muscle (myopericarditis). Significant troponin elevation warrants further evaluation. Complete blood count, kidney function tests, and thyroid function tests help identify potential underlying causes.

Additional Testing

A chest X-ray may appear normal in uncomplicated pericarditis but can show an enlarged cardiac silhouette if a large pericardial effusion is present. CT scan or cardiac MRI may be useful in selected cases to better visualize the pericardium, detect thickening or enhancement indicating inflammation, and identify underlying causes. These advanced imaging tests are particularly helpful in cases of recurrent or constrictive pericarditis.

How Is Pericarditis Treated?

First-line treatment for acute pericarditis is NSAIDs (ibuprofen 600mg three times daily or aspirin 750-1000mg three times daily) combined with colchicine (0.5mg once or twice daily) for 3 months. This combination reduces symptoms and cuts recurrence risk by approximately 50%. Rest and avoiding strenuous activity are essential during recovery.

The treatment of pericarditis depends on the underlying cause, severity, and clinical context. For most cases of idiopathic or viral pericarditis, the goal is to reduce inflammation, relieve symptoms, and prevent recurrence. The European Society of Cardiology guidelines provide a structured approach to treatment that has been validated in clinical trials.

First-Line Treatment: NSAIDs Plus Colchicine

Non-steroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of pericarditis treatment. The most commonly used options are:

• Ibuprofen: 600mg three times daily (1800mg total daily dose)
• Aspirin: 750-1000mg three times daily (especially preferred after heart attack due to its antiplatelet effects)
• Indomethacin: 50mg three times daily (an alternative but with more side effects)

NSAIDs should be taken with food or with a proton pump inhibitor to protect the stomach lining. Treatment continues until symptoms resolve and inflammatory markers (CRP) normalize, typically 1-2 weeks for a first episode. The dose is then tapered gradually over several weeks rather than stopped abruptly, as abrupt discontinuation increases recurrence risk.

Colchicine has been shown in multiple randomized controlled trials (COPE, CORE, CORP, CORP-2 trials) to significantly reduce the risk of recurrent pericarditis when added to NSAID therapy. The mechanism involves inhibiting inflammation by affecting white blood cell function. Colchicine is dosed at 0.5mg twice daily (or 0.5mg once daily for patients under 70kg or who have intolerance at higher doses). Current guidelines recommend colchicine for 3 months for a first episode and for 6 months for recurrent episodes. The combination of NSAIDs plus colchicine reduces recurrence from approximately 30% to approximately 15%.

Rest and Activity Restriction

Physical rest is an important component of pericarditis treatment that is often underemphasized. The European Society of Cardiology recommends restriction of physical activity beyond ordinary sedentary life until symptoms resolve and inflammatory markers normalize. For athletes, return to competitive sports should be delayed for at least 3 months after complete resolution. This recommendation is based on concerns that physical exertion during active pericarditis may worsen inflammation or increase the risk of complications.

Corticosteroids

Corticosteroids are not first-line treatment for most cases of pericarditis because they have been associated with increased risk of recurrence and chronicity. However, corticosteroids may be indicated in specific situations:

• When NSAIDs are contraindicated (e.g., kidney disease, recent gastrointestinal bleeding, allergy)
• When there is an underlying autoimmune disease that requires steroids
• When first-line treatment has failed
• In pregnancy, where NSAID use is limited

When corticosteroids are necessary, they should be used at low to moderate doses (prednisone 0.25-0.5mg/kg/day) and tapered very slowly over months, always in combination with colchicine.

Treatment of Specific Causes

When a specific underlying cause is identified, treatment should target that cause. Bacterial pericarditis requires appropriate antibiotics and often surgical drainage. Tuberculous pericarditis requires anti-tuberculosis therapy and often corticosteroids to reduce the risk of constrictive pericarditis. Uremic pericarditis responds to intensification of dialysis. Malignant pericarditis requires treatment of the underlying cancer and may need pericardial drainage or pericardial window procedure.

Managing Recurrent Pericarditis

For patients with recurrent pericarditis despite optimal therapy with NSAIDs and colchicine, additional options include low-dose corticosteroids as described above, and for refractory cases, newer biological therapies such as anakinra (an interleukin-1 receptor antagonist) which has shown excellent results in steroid-dependent recurrent pericarditis.

What Are the Complications of Pericarditis?

The main complications of pericarditis are pericardial effusion (fluid accumulation), cardiac tamponade (life-threatening compression of the heart), constrictive pericarditis (chronic scarring), and recurrence (occurring in 15-30% of cases). Most complications are rare with proper treatment, but prompt recognition is essential.

While most cases of acute pericarditis resolve without complications, awareness of potential complications is important for both patients and healthcare providers. Early recognition allows for prompt treatment and better outcomes.

Pericardial Effusion

Pericardial effusion refers to excessive fluid accumulation in the pericardial space. Small effusions are common in pericarditis and often resolve without specific treatment as the underlying inflammation subsides. Larger effusions may cause symptoms such as shortness of breath, discomfort when lying flat, or a sense of fullness in the chest. The rate of fluid accumulation is as important as the total volume—slowly accumulating effusions allow the pericardium to stretch and accommodate larger volumes, while rapidly accumulating effusions can cause problems even at smaller volumes.

Cardiac Tamponade

Cardiac tamponade is the most serious acute complication of pericarditis. It occurs when pericardial fluid accumulates to the point where it compresses the heart chambers, preventing them from filling properly and dramatically reducing cardiac output. Signs of tamponade include severe shortness of breath, low blood pressure, distended neck veins, and muffled heart sounds (Beck's triad). Cardiac tamponade is a medical emergency requiring urgent pericardiocentesis (needle drainage of the fluid) or surgical drainage.

Constrictive Pericarditis

Constrictive pericarditis is a chronic complication where scarring and thickening of the pericardium creates a rigid shell around the heart, limiting its ability to expand and fill properly. This typically develops over months to years and is most common after bacterial or tuberculous pericarditis, or after radiation therapy. Symptoms include progressive fatigue, shortness of breath, leg swelling, and abdominal distension. Treatment may ultimately require surgical removal of the pericardium (pericardiectomy).

Recurrent Pericarditis

Recurrence is the most common complication, occurring in approximately 15-30% of patients after a first episode. With the addition of colchicine to initial treatment, recurrence rates have decreased significantly. Risk factors for recurrence include not using colchicine, high CRP at diagnosis, suboptimal NSAID dosing, and use of corticosteroids. Most recurrences respond well to the same treatment as the initial episode, though a longer course of colchicine is recommended.

When Should You Seek Medical Care?

Seek medical care promptly for any chest pain to rule out heart attack. Call emergency services immediately for severe chest pain, difficulty breathing, feeling faint, or signs of shock. Once diagnosed with pericarditis, contact your doctor if symptoms worsen, fever develops, or symptoms persist despite treatment.

Any chest pain warrants medical evaluation to differentiate between various causes, some of which (like heart attack) require urgent treatment. While pericarditis itself is usually not immediately life-threatening, the complications can be, and the symptoms can sometimes be difficult to distinguish from more serious conditions.

Seek emergency care immediately if you experience:

• Severe chest pain or pressure
• Significant difficulty breathing
• Feeling faint or actually losing consciousness
• Signs of shock (pale, cold, clammy skin; confusion; rapid heart rate)

Contact your healthcare provider promptly if you have diagnosed pericarditis and develop:

• Worsening chest pain despite treatment
• New or worsening shortness of breath
• Fever above 38°C/100.4°F
• Symptoms not improving after 1 week of treatment
• Significant side effects from medications

What Is the Outlook for Pericarditis?

The prognosis for most cases of acute pericarditis is excellent. Approximately 70-90% of patients recover completely within 1-3 weeks with appropriate treatment. While recurrence occurs in 15-30% of cases, most recurrences also respond well to treatment. Serious complications like cardiac tamponade or constrictive pericarditis are rare.

The vast majority of patients with acute idiopathic or viral pericarditis have an excellent prognosis. With appropriate treatment, symptoms typically improve within days, and complete resolution occurs within 1-3 weeks. The main concern is recurrence, which can be frustrating and impact quality of life but generally responds to treatment.

Certain factors are associated with a higher risk of complications or poorer outcomes, known as high-risk features:

• High fever (above 38°C/100.4°F)
• Subacute onset (symptoms developing over weeks rather than days)
• Large pericardial effusion or cardiac tamponade
• Lack of response to NSAID treatment within 1 week
• Known immunosuppression
• Trauma or recent cardiac surgery
• Oral anticoagulant therapy (increases risk of hemorrhagic effusion)
• Elevated cardiac troponin suggesting myocardial involvement

Patients with these high-risk features may require hospitalization for closer monitoring and more intensive evaluation for underlying causes.

Long-term outcomes are generally good. Studies following patients for years after an episode of pericarditis show that most have no lasting cardiac problems. The development of constrictive pericarditis is rare (less than 1%) in idiopathic/viral pericarditis but higher in specific causes such as bacterial (20-30%) or tuberculous (30-50%) pericarditis.