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Acute pericarditis

Background

Overview

Definition
Acute pericarditis is a disease characterized by acute inflammation of the pericardium.
1
Pathophysiology
Most cases of acute pericarditis are idiopathic (80-90%) and assumed to be due to viral infection. Other important causes include post-cardiac injury syndromes, connective tissue diseases (such as SLE), and cancer.
2
Epidemiology
In the US, the incidence of acute pericarditis requiring hospitalization is estimated at 26 cases per 100,000 person-years.
3
Disease course
Inflammation of the pericardium results in the formation of a pericardial effusion, which may progress to cardiac tamponade and obstructive shock.
2
Prognosis and risk of recurrence
Acute pericarditis is associated with 5.7% all-cause mortality at 30 days, and 17.3% all-cause mortality at 1 year.
3

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute pericarditis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the European Society for Microbiology and Infectious Diseases (ESCMID 2022), the European Society of Cardiology (ESC/ESTRO/EHA/IC-OS 2022), the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the Society of Cardiovascular Computed ...
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Screening and diagnosis

Diagnostic criteria: as per EACTS/ESC 2015 guidelines, make a clinical diagnosis of acute pericarditis in patients with ≥ 2 out of 4 suggestive clinical criteria (chest pain, pericardial rub, ECG changes, and pericardial effusion).
Diagnostic criteria for acute pericarditis
Characteristic symptoms of chest pain (typically sharp and pleuritic, improved by sitting up and leaning forward)
Pericardial friction rub (a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border)
Typical ECG changes (new diffuse ST segment elevation or PR depression in acute phase)
Pericardial effusion identified on diagnostic imaging (such as echocardiogram or CT)
Acute pericarditis is unlikely
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Diagnostic investigations

Initial evaluation: as per AAFP 2024 guidelines, obtain the following in the initial evaluation for acute pericarditis:
history and physical examination
ECG
CXR
TTE
baseline laboratory tests.
B

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  • TTE

  • Cardiac MRI/CT

  • Evaluation for viral pericarditis

Diagnostic procedures

Coronary angiography: as per EACTS/ESC 2015 guidelines, perform coronary angiography (according to clinical presentation and risk factor assessment) to rule out acute coronary syndromes in patients with pericarditis and suspected myocarditis.
B

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  • Diagnostic pericardiocentesis

  • Pericardial biopsy

Medical management

Setting of care: as per AAFP 2024 guidelines, admit patients with acute pericarditis having risk factors for serious disease or complications to the hospital for further treatment and etiologic workup.
B

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  • General principles

  • NSAIDs

  • Colchicine

  • Corticosteroids

  • Management of recurrent pericarditis

Nonpharmacologic interventions

Exercise restrictions: as per AAFP 2024 guidelines, advise avoiding participation in competitive sports for athletes with acute pericarditis for 3 months after diagnosis or for 3-6 months after diagnosing myopericarditis.
B

Specific circumstances

Pediatric patients: as per EACTS/ESC 2015 guidelines, administer NSAIDs at high doses as first-line therapy for acute pericarditis in pediatric patients until complete symptom resolution.
B
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  • Patients with purulent pericarditis

  • Patients with uremic pericarditis

  • Patients with post-cardiac injury syndromes

  • Patients with radiation pericarditis

  • Patients chemotherapy-induced pericarditis

  • Patients with neoplastic pericardial disease

  • Patients with SLE

  • Patients with relapsing polychondritis

  • Patients with polyarteritis nodosa

  • Patients with Lyme disease

  • Patients with Chagas disease

  • Patients with lightning injury

  • Patients with long COVID

  • Patients with AIS

  • Patients with tuberculous pericarditis

Follow-up and surveillance

Follow-up
As per EACTS/ESC 2015 guidelines:
Schedule follow-up 1 week after treatment initiation to assess response to anti-inflammatory therapy.
B
Consider obtaining echocardiography every 6-12 months after post-cardiac injury pericarditis to exclude possible evolution toward constrictive pericarditis.
C