(Note: For PDF File Swipe To The End Of Article)
Introduction
Pericarditis is an inflammatory disorder involving the pericardium, the fibroserous sac that surrounds the heart. Although the pericardium is often thought of simply as a protective covering, it has several important physiological functions. It helps maintain the heart in its anatomical position, limits sudden cardiac distension, provides a relatively friction-free environment for cardiac movement, and separates the heart from surrounding thoracic structures.
Inflammation of this sac can produce a characteristic type of chest pain, a pericardial friction rub, electrocardiographic abnormalities, and sometimes accumulation of fluid within the pericardial cavity. The clinical spectrum is broad. Some patients experience a mild, self-limited episode, while others develop recurrent inflammation, large pericardial effusion, cardiac tamponade, or constrictive pericarditis.
Pericarditis is particularly important because its presentation can closely resemble other causes of acute chest pain, including acute myocardial infarction, pulmonary embolism, aortic dissection, pneumonia, and gastroesophageal disease. Recognition of the characteristic clinical pattern is therefore essential.
Current understanding also recognizes that pericardial inflammation may overlap with inflammation of the myocardium. The 2025 European Society of Cardiology guidelines use the broader concept of inflammatory myopericardial syndrome to describe the spectrum ranging from isolated pericarditis to myocarditis and mixed forms. Modern evaluation increasingly incorporates biomarkers and multimodality imaging, particularly echocardiography and cardiovascular magnetic resonance.
Definition
Pericarditis is an inflammatory condition of the pericardial sac, with or without associated pericardial effusion. The inflammation may be acute, persistent, recurrent, or chronic depending on its duration and clinical course.
The pericardium consists primarily of two layers. The visceral layer closely covers the heart, while the parietal layer forms the outer fibrous and serous covering. A small amount of fluid normally exists between these layers, allowing relatively smooth movement of the heart during systole and diastole.
When inflammation develops, the pericardial surfaces may become roughened and produce friction during cardiac movement. This can result in the characteristic pericardial friction rub. Inflammatory exudation may also increase the amount of fluid within the pericardial cavity, producing a pericardial effusion.
Pericarditis may occur as an isolated disease or as part of a systemic inflammatory, infectious, autoimmune, malignant, metabolic, traumatic, or post-cardiac-injury process.
Anatomy and Physiology of the Pericardium
Understanding the anatomy of the pericardium makes the clinical manifestations of pericarditis easier to understand.
The pericardium surrounds the heart and proximal portions of the great vessels. It is composed of a tough outer fibrous layer and an inner serous component. The serous pericardium has parietal and visceral layers.
The pericardial cavity lies between the serous layers and normally contains a small volume of lubricating fluid. Under normal conditions, this fluid allows the heart to move with minimal friction.
The fibrous pericardium also provides mechanical protection. It helps prevent excessive acute expansion of the cardiac chambers. This property becomes clinically important when fluid accumulates rapidly inside the pericardial cavity.
A slowly developing effusion may sometimes become very large before producing severe hemodynamic compromise because the pericardium can gradually stretch. In contrast, a rapidly accumulating relatively small effusion can markedly increase intrapericardial pressure and cause cardiac tamponade.
Thus, the clinical significance of an effusion depends not only on its absolute volume but also on the rate at which it develops, the compliance of the pericardium, and the underlying cardiac and systemic conditions.
Classification of Pericarditis
Pericarditis can be classified according to its duration, clinical course, underlying cause, and pathological characteristics.
Classification According to Clinical Course
Acute pericarditis develops over a relatively short period and is usually characterized by acute inflammatory chest pain, ECG changes, and/or pericardial effusion.
Incessant or persistent pericarditis refers to inflammation that does not adequately resolve and continues beyond the expected acute course.
Recurrent pericarditis occurs when a patient experiences a new episode after a symptom-free period following an initial episode.
Chronic pericarditis represents prolonged pericardial inflammation. It may be associated with chronic effusion, thickening, fibrosis, or constrictive physiology.
Classification According to Cause
Pericarditis can be divided into:
- Infectious pericarditis
- Idiopathic or presumed viral pericarditis
- Autoimmune or systemic inflammatory pericarditis
- Post-cardiac injury pericarditis
- Malignant pericarditis
- Uremic pericarditis
- Drug-induced pericarditis
- Traumatic pericarditis
- Radiation-associated pericarditis
- Purulent bacterial pericarditis
- Tuberculous pericarditis
- Pericarditis associated with metabolic or systemic diseases
In many patients, particularly in otherwise healthy individuals, no specific pathogen or systemic cause is demonstrated. Such cases are often classified clinically as idiopathic or presumed viral pericarditis rather than proven viral infection.
Causes and Etiology
The causes of pericarditis are numerous. Identifying the underlying etiology is important because treatment can differ substantially between uncomplicated inflammatory pericarditis and specific causes such as tuberculosis, malignancy, purulent infection, autoimmune disease, or uremia.
Viral Infections
Viral infections are among the common presumed causes of acute pericarditis. Various viruses can be associated with inflammation of the pericardium.
Patients may report a recent upper respiratory tract infection, gastrointestinal illness, fever, malaise, or other viral symptoms before the onset of chest pain.
However, demonstrating a virus as the direct cause of pericarditis is often difficult. Therefore, a clinically diagnosed case without definitive microbiological or tissue confirmation is generally described as presumed viral or idiopathic rather than definitively viral.
Bacterial Infections
Bacterial pericarditis is less common than presumed viral or idiopathic disease but can be severe.
It may occur through direct spread from nearby infections, bloodstream infection, thoracic infection, surgery, trauma, or other systemic sources.
Purulent bacterial pericarditis is a medical emergency because it can rapidly lead to tamponade, sepsis, and death without prompt treatment.
Tuberculosis
Tuberculosis is an important cause of pericarditis in regions where tuberculosis is prevalent.
Tuberculous pericarditis may develop gradually and can present with fever, night sweats, weight loss, fatigue, chest discomfort, or persistent pericardial effusion.
Without appropriate treatment, tuberculosis can produce chronic inflammation and fibrosis, potentially leading to constrictive pericarditis.
Autoimmune and Rheumatologic Diseases
Pericarditis can occur in association with systemic inflammatory diseases, including:
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Systemic sclerosis
- Sjögren syndrome
- Vasculitic disorders
- Adult-onset Still disease
- Other systemic autoimmune disorders
In these patients, pericarditis may occur together with other manifestations of systemic inflammation.
Post-Cardiac Injury Syndromes
Pericarditis may develop after myocardial infarction, cardiac surgery, catheter-based procedures, or other cardiac injury.
The inflammatory response may occur immediately or after a delay and is sometimes called a post-cardiac injury syndrome.
Uremia
Severe renal dysfunction can produce uremic pericarditis. It is generally associated with significant renal impairment and may occur in patients with advanced kidney disease.
Recognition is important because management involves treatment of the underlying renal failure in addition to appropriate management of the pericardial inflammation.
Malignancy
Cancer can involve the pericardium either through direct extension, metastatic spread, lymphatic involvement, or other mechanisms.
Malignant pericardial disease may cause recurrent or large pericardial effusions and can sometimes lead to tamponade.
Common malignancies associated with pericardial involvement include lung cancer, breast cancer, hematologic malignancies, and other metastatic cancers.
Drug-Induced Pericarditis
Several medications have been associated with pericardial inflammation or lupus-like syndromes that can involve the pericardium.
The medication history is therefore an important part of the evaluation, particularly in patients with recurrent or unexplained pericarditis.
Radiation
Previous mediastinal radiation can damage the pericardium and may produce inflammation, fibrosis, effusion, or later constrictive disease.
Trauma
Blunt or penetrating chest trauma can injure the pericardium and may cause bleeding into the pericardial cavity.
Hemopericardium can rapidly produce cardiac tamponade and requires urgent assessment.
Pathophysiology
The central event in pericarditis is inflammation of the pericardial tissues.
An initiating stimulus such as infection, tissue injury, autoimmune activation, malignancy, metabolic disturbance, or another inflammatory trigger activates the immune system. Inflammatory mediators increase vascular permeability and promote recruitment of inflammatory cells.
The inflamed pericardial surfaces become edematous and hyperemic. Fibrin deposition may occur over the pericardial surfaces. This fibrinous inflammation produces the roughened surfaces responsible for the characteristic friction rub.
Inflammation can also stimulate production of pericardial fluid. Depending on the cause, the fluid may be serous, fibrinous, hemorrhagic, purulent, or otherwise abnormal.
If fluid accumulates gradually, the pericardium may stretch and accommodate a considerable volume. If accumulation is rapid, however, intrapericardial pressure may rise quickly.
As intrapericardial pressure approaches the filling pressures of the cardiac chambers, particularly the right-sided chambers, diastolic filling becomes impaired. Venous return may decrease, cardiac output may fall, and the patient may develop cardiac tamponade.
Repeated or persistent inflammation can also result in organization of fibrin, fibrosis, scarring, and thickening of the pericardium. In advanced cases, the pericardium may become rigid and interfere with normal ventricular filling, producing constrictive pericarditis.
The inflammatory mechanisms underlying recurrent pericarditis are increasingly understood to include both adaptive immune and autoinflammatory pathways. This has contributed to the development of targeted therapies, including interleukin-1 pathway inhibition in selected patients with recurrent disease.
Clinical Features
The clinical presentation of pericarditis varies according to its cause, severity, duration, and the presence or absence of complications.
The most characteristic symptom is sharp, pleuritic chest pain. However, patients can also present with fever, weakness, shortness of breath, palpitations, or symptoms caused by an associated pericardial effusion.
A careful history is particularly important because many features of pericarditic pain distinguish it from myocardial ischemia.
Symptoms
Chest Pain
Chest pain is the classic symptom of acute pericarditis.
The pain is often:
- Sharp or stabbing
- Central or left-sided
- Worse with deep inspiration
- Worse with coughing
- Worse when lying flat
- Improved by sitting upright
- Improved by leaning forward
The positional nature of the pain is particularly characteristic.
Unlike typical ischemic chest pain, which is often described as pressure, heaviness, squeezing, or tightness, pericarditic pain tends to have a pleuritic and positional character.
Nevertheless, these distinctions are not sufficient by themselves to exclude acute coronary syndrome. Any patient presenting with significant acute chest pain requires appropriate assessment for potentially life-threatening causes.
Fever
Low-grade fever may accompany inflammatory pericarditis, especially when an infectious or systemic inflammatory cause is present.
High fever should increase suspicion for a specific or complicated cause, including bacterial infection.
Dyspnea
Shortness of breath may occur because pain makes deep inspiration uncomfortable.
Dyspnea can also develop when a significant pericardial effusion interferes with cardiac filling or when inflammation overlaps with myocardial involvement.
Palpitations
Patients may report awareness of their heartbeat. Palpitations may result from sinus tachycardia caused by pain or inflammation, or from associated arrhythmias when myocardial involvement is present.
Fatigue and Malaise
Generalized weakness, tiredness, reduced exercise tolerance, and malaise are common nonspecific manifestations of systemic inflammation.
Symptoms of Underlying Disease
Patients may also have symptoms pointing toward the underlying cause.
For example, a patient with autoimmune disease may have joint pain or skin manifestations, while a patient with tuberculosis may have constitutional symptoms such as weight loss and night sweats.
Signs
Pericardial Friction Rub
The classic physical finding of acute pericarditis is a pericardial friction rub.
It is produced by the inflamed pericardial layers rubbing against one another.
The rub may have a scratchy or grating quality and can vary during the cardiac cycle. It may become more prominent when the patient leans forward.
Importantly, a friction rub may be transient. Its absence therefore does not exclude pericarditis.
Tachycardia
Sinus tachycardia may occur because of fever, pain, anxiety, inflammation, reduced cardiac output, or another associated condition.
Fever
Fever may be present when systemic inflammation or infection accompanies pericarditis.
Hypotension
Hypotension is particularly concerning when associated with a significant pericardial effusion and possible cardiac tamponade.
Elevated Jugular Venous Pressure
Raised jugular venous pressure may occur when cardiac filling is impaired, especially in tamponade or constrictive pericarditis.
Pulsus Paradoxus
Pulsus paradoxus refers to an exaggerated inspiratory fall in systolic blood pressure. It may occur in cardiac tamponade, although its presence and degree depend on the clinical circumstances.
Muffled Heart Sounds
Heart sounds may become distant or muffled when a large pericardial effusion surrounds the heart.
Diagnostic Criteria
The diagnosis of acute pericarditis is primarily clinical and is supported by ECG, laboratory testing, and imaging.
Traditionally, acute pericarditis is diagnosed when at least two characteristic clinical criteria are present:
- Typical pericarditic chest pain
- Pericardial friction rub
- Characteristic ECG changes
- New or worsening pericardial effusion
Inflammatory markers and imaging evidence of pericardial inflammation provide additional supportive information. The 2025 ESC approach emphasizes individualized evaluation using clinical assessment, ECG, biomarkers, echocardiography, and, when appropriate, cardiovascular magnetic resonance.
History Taking
A detailed history should establish the nature of the chest pain, associated symptoms, recent illnesses, medical history, medications, and risk factors for specific etiologies.
Important questions include:
- When did the pain begin?
- Was the onset sudden or gradual?
- Is the pain sharp or pressure-like?
- Does it worsen with inspiration?
- Does it improve when sitting forward?
- Has there been a recent respiratory or gastrointestinal infection?
- Is there fever?
- Has there been recent cardiac surgery or an invasive cardiac procedure?
- Is there known autoimmune disease?
- Is there renal failure?
- Is there a history of tuberculosis exposure?
- Is there known malignancy?
- Has the patient received chest radiation?
- What medications are being used?
- Has the patient experienced previous episodes of pericarditis?
A history of previous episodes is especially important because recurrent pericarditis may require a different long-term management strategy from a first uncomplicated episode.
Investigations
The investigation of suspected pericarditis aims to establish the diagnosis, assess severity, identify myocardial involvement, detect pericardial effusion, and determine the underlying cause.
The major investigations include:
- Electrocardiography
- Complete blood count
- C-reactive protein
- Erythrocyte sedimentation rate
- Cardiac troponin
- Renal function tests
- Electrolytes
- Liver function tests when clinically indicated
- Chest radiography
- Transthoracic echocardiography
- Cardiac magnetic resonance
- Computed tomography in selected cases
- Microbiological studies when infection is suspected
- Autoimmune testing when indicated
- Pericardial fluid analysis in selected patients
Electrocardiogram Changes
ECG abnormalities are among the most useful findings in acute pericarditis.
The classic ECG pattern consists of widespread, relatively diffuse ST-segment elevation accompanied by PR-segment depression.
The changes are not usually confined to a single coronary artery territory.
A typical sequence has traditionally been described in stages.
Stage I
There is widespread concave ST-segment elevation, often accompanied by PR-segment depression.
Stage II
The ST segments return toward baseline. T-wave changes may become less prominent.
Stage III
T-wave inversion may develop after the ST segments have normalized.
Stage IV
The ECG gradually returns toward the patient's baseline.
Not every patient passes through all four stages, and ECG findings can vary considerably.
PR-segment depression is particularly supportive of pericardial inflammation, while PR elevation in lead aVR may be seen as a reciprocal finding.
Differentiating Pericarditis From Acute Myocardial Infarction
One of the most important diagnostic challenges is distinguishing acute pericarditis from acute coronary syndrome.
Pericarditis often produces diffuse, concave ST elevation, whereas acute myocardial infarction typically produces ST elevation localized to a coronary arterial territory.
Pericarditis may also produce PR depression.
In myocardial infarction, the pain is often pressure-like and may radiate to the arm, shoulder, jaw, or back, although considerable overlap exists.
Troponin elevation can occur in pericarditis when inflammation involves the myocardium. This situation is sometimes described as myopericarditis or perimyocarditis, depending on the predominant clinical involvement.
Because these conditions can overlap, ECG interpretation should always be integrated with clinical assessment, cardiac biomarkers, echocardiography, and other appropriate investigations.
Blood Tests
Complete Blood Count
A CBC can demonstrate leukocytosis or other hematological abnormalities.
An elevated white blood cell count may support an inflammatory or infectious process but is nonspecific.
C-Reactive Protein
CRP is an important marker of systemic inflammation.
It can support the diagnosis, help assess inflammatory activity, and assist in monitoring response to treatment.
Persistent elevation may suggest ongoing inflammation and can be particularly relevant in recurrent or incessant disease.
Erythrocyte Sedimentation Rate
ESR may also be elevated.
Although less specific and slower to change than CRP, it can provide additional evidence of systemic inflammation.
Cardiac Troponin
Troponin is important for identifying myocardial involvement.
A significant troponin elevation should prompt careful evaluation for myocardial injury and possible myocarditis or myopericarditis, as well as consideration of acute coronary syndrome when clinically appropriate.
Renal Function
Serum creatinine and other measures of renal function are important because severe renal disease can cause pericarditis and because renal function influences the safety and dosing of several medications.
Echocardiography
Transthoracic echocardiography is one of the most important imaging investigations in suspected pericarditis.
It can detect:
- Pericardial effusion
- Chamber compression
- Features of cardiac tamponade
- Ventricular function
- Abnormal cardiac filling
- Associated structural abnormalities
Importantly, a normal echocardiogram does not exclude acute pericarditis because inflammation can occur without a significant effusion.
Echocardiography becomes particularly urgent when the patient is hypotensive, tachycardic, has elevated jugular venous pressure, has muffled heart sounds, or otherwise appears to have hemodynamic compromise.
Cardiac Magnetic Resonance Imaging
Cardiovascular magnetic resonance has become increasingly important in the evaluation of inflammatory pericardial and myocardial disease.
CMR can provide information about:
- Pericardial edema
- Pericardial inflammation
- Pericardial enhancement
- Myocardial inflammation
- Myocardial edema
- Ventricular function
- Associated myocardial injury
The 2025 ESC guidelines emphasize multimodality imaging, with CMR playing a central role in non-invasive assessment of myocardial and pericardial inflammation, particularly when the diagnosis is uncertain or myocardial involvement needs clarification.
Computed Tomography
CT can provide useful anatomical information about the pericardium.
It can demonstrate:
- Pericardial thickening
- Pericardial calcification
- Pericardial effusion
- Adjacent lung disease
- Mediastinal abnormalities
- Masses or lymphadenopathy
CT can be especially helpful when malignancy, tuberculosis, trauma, or other thoracic pathology is being considered.
Chest X-Ray
A chest radiograph may be normal in uncomplicated acute pericarditis.
When a large pericardial effusion develops, however, the cardiac silhouette may become enlarged.
Chest radiography is also useful for identifying alternative or associated thoracic conditions, such as pneumonia, pulmonary edema, pleural disease, or malignancy.
Pericardial Effusion
Pericardial effusion refers to abnormal accumulation of fluid within the pericardial cavity.
The fluid may accumulate because of inflammation, infection, malignancy, trauma, renal disease, systemic disorders, or other causes.
Small effusions may produce few or no symptoms.
Larger effusions can produce dyspnea, chest discomfort, tachycardia, and eventually hemodynamic compromise.
The speed of accumulation is crucial. Rapid accumulation can produce tamponade even when the total volume is not extremely large, whereas slowly developing effusions may become considerably larger before producing severe symptoms.
Cardiac Tamponade
Cardiac tamponade is a life-threatening complication in which increased intrapericardial pressure impairs cardiac chamber filling and reduces cardiac output.
As pressure rises, the right atrium and right ventricle are particularly vulnerable during diastole because their intracardiac pressures are relatively low.
Reduced ventricular filling decreases stroke volume and cardiac output.
The patient may develop:
- Hypotension
- Tachycardia
- Raised jugular venous pressure
- Muffled heart sounds
- Pulsus paradoxus
- Dyspnea
- Weak peripheral pulses
- Altered mental status in severe cases
- Shock
Echocardiography is central to diagnosis.
Cardiac tamponade requires urgent medical evaluation and, when clinically significant, drainage of the pericardial fluid. The specific drainage approach depends on the cause, anatomy, hemodynamic status, and clinical setting.
Risk Stratification
Not all patients with pericarditis have the same prognosis.
Risk assessment helps determine whether outpatient management is reasonable or whether hospital evaluation is required.
Features that raise concern include:
- High fever
- Subacute onset
- Large pericardial effusion
- Cardiac tamponade
- Failure to respond to initial anti-inflammatory treatment
- Suspected bacterial infection
- Suspected tuberculosis
- Suspected malignancy
- Immunosuppression
- Significant myocardial involvement
- Major associated systemic disease
- Recurrent or persistent disease
The 2025 ESC framework emphasizes presentation-driven assessment and individualized risk stratification rather than treating every patient with pericarditis as having an identical clinical course.
Differential Diagnosis
Because chest pain is the dominant symptom, several potentially dangerous diseases must be considered.
Acute Coronary Syndrome
Acute coronary syndrome should always be considered in a patient with acute chest pain.
ECG findings, troponin levels, pain characteristics, risk factors, and imaging help differentiate ischemic disease from pericarditis.
Pulmonary Embolism
Pulmonary embolism may produce pleuritic chest pain and dyspnea.
Risk factors, oxygen saturation, ECG, imaging, and appropriate laboratory testing help establish the diagnosis.
Aortic Dissection
Aortic dissection can cause sudden severe chest or back pain and is a medical emergency.
The pain may be abrupt and maximal at onset, and patients may have pulse differences, neurological findings, or hemodynamic instability.
Pneumonia and Pleuritis
Pneumonia may produce fever, cough, dyspnea, and pleuritic chest pain.
Chest imaging can help distinguish pulmonary infection from pericardial inflammation.
Myocarditis and Myopericarditis
Myocarditis can overlap considerably with pericarditis.
Troponin elevation, ventricular dysfunction, arrhythmias, and CMR findings may indicate significant myocardial involvement.
Gastroesophageal Causes
Gastroesophageal reflux and esophageal disorders can produce chest discomfort and may mimic cardiac pain.
However, cardiac and other life-threatening causes should be appropriately excluded before attributing acute chest pain to gastrointestinal disease.
Treatment and Management
Treatment depends on the cause, severity, clinical presentation, presence of complications, and whether the disease is a first episode or recurrent.
For uncomplicated inflammatory pericarditis, treatment generally aims to suppress inflammation, relieve pain, shorten the active inflammatory period, and prevent recurrence.
When a specific cause is identified, therapy must be directed toward that cause.
The 2025 ESC guidelines recommend anti-inflammatory therapy and colchicine as central components of treatment for uncomplicated pericarditis, with additional targeted approaches for selected complicated or recurrent cases.
Nonsteroidal Anti-Inflammatory Drugs
NSAIDs are commonly used as first-line anti-inflammatory therapy for acute pericarditis.
Examples include:
- Ibuprofen
- Aspirin
- Other appropriate NSAIDs depending on the clinical situation
The choice of drug depends on the patient's age, renal function, gastrointestinal risk, cardiovascular status, concomitant medications, and underlying cause.
Anti-inflammatory treatment is generally continued according to clinical response and inflammatory markers rather than simply stopping immediately after symptom improvement.
A proton-pump inhibitor may be used for gastrointestinal protection when appropriate.
Current ESC guidance recommends high-dose aspirin or NSAIDs with proton-pump inhibitor protection as first-line therapy for pericarditis.
Colchicine
Colchicine is an important medication in the treatment of acute and recurrent pericarditis.
It is generally used as an adjunct to anti-inflammatory therapy rather than as a replacement for appropriate first-line anti-inflammatory treatment.
Its major clinical benefit is reduction in the risk of recurrent pericarditis.
The dose and duration depend on factors such as body weight, renal function, age, drug interactions, and the specific clinical situation.
Important adverse effects include gastrointestinal symptoms, particularly diarrhea and abdominal discomfort.
Colchicine requires caution or dose adjustment in patients with significant renal or hepatic impairment and with certain interacting medications.
The 2025 ESC guidelines recommend colchicine as first-line adjunctive therapy to reduce subsequent recurrences.
Corticosteroids
Corticosteroids can rapidly suppress inflammation, but they are generally not preferred as routine first-line therapy for uncomplicated pericarditis when NSAIDs and colchicine are appropriate.
Steroids may be considered when:
- NSAIDs are contraindicated
- NSAIDs are ineffective or poorly tolerated
- There is a specific indication for corticosteroid therapy
- An autoimmune or systemic inflammatory disease requires steroid treatment
- Selected complicated or recurrent cases require them
An important concern is that corticosteroid exposure can be associated with an increased tendency toward recurrent pericarditis in some patients, particularly when used early or withdrawn too rapidly.
Therefore, when corticosteroids are required, treatment should be carefully individualized and tapered appropriately under medical supervision.
Interleukin-1 Inhibitors
Recurrent inflammatory pericarditis has led to the development of targeted anti-inflammatory treatment.
Interleukin-1 plays an important role in the inflammatory cascade involved in recurrent pericarditis.
Two important agents include:
- Anakinra
- Rilonacept
These therapies are particularly relevant in patients with recurrent disease that remains active despite conventional treatment or who cannot successfully discontinue corticosteroids.
The 2025 ESC guidelines recommend anti-IL-1 therapy for selected recurrent pericarditis patients after failure of first-line therapy and corticosteroids, particularly when inflammatory activity is present.
Treatment of Specific Causes
Tuberculous Pericarditis
Tuberculous pericarditis requires appropriate anti-tuberculosis therapy.
The exact regimen depends on local guidelines, drug susceptibility, patient factors, and whether other organs are involved.
Selected patients may also require corticosteroid therapy depending on the clinical circumstances and guideline recommendations.
Purulent Pericarditis
Purulent pericarditis requires urgent treatment.
Management typically involves:
- Prompt antimicrobial therapy
- Pericardial drainage
- Microbiological examination of fluid
- Identification of the infectious source
- Surgical intervention in selected patients
Delay in treatment can result in sepsis, tamponade, constriction, and death.
Uremic Pericarditis
Management focuses on correcting severe renal dysfunction, usually through appropriate renal replacement therapy when indicated.
Anti-inflammatory therapy may need to be adapted because renal impairment can alter the safety of commonly used medications.
Malignant Pericardial Disease
Treatment depends on the underlying cancer and the severity and recurrence of the effusion.
Drainage may be required in symptomatic or hemodynamically significant effusion, and longer-term strategies may be considered for recurrent malignant effusions.
Pericardiocentesis
Pericardiocentesis is a procedure in which fluid is removed from the pericardial cavity using a needle or catheter.
It can be diagnostic, therapeutic, or both.
Important indications include:
- Cardiac tamponade
- Large symptomatic effusion in selected patients
- Suspected purulent pericarditis
- Suspected malignant pericardial disease
- Selected unexplained or persistent effusions where fluid analysis is needed
Pericardial fluid may be sent for:
- Cell count
- Protein and biochemical studies
- Cytology
- Bacterial culture
- Fungal studies
- Tuberculosis testing
- Other microbiological or molecular studies when indicated
The procedure should be performed by appropriately trained clinicians using suitable imaging guidance whenever feasible.
Surgical Management
Some patients require surgical management rather than needle drainage alone.
Surgical options may include:
- Pericardial window
- Surgical drainage
- Pericardiectomy
A pericardial window may be considered in selected patients with recurrent effusion, particularly when repeated drainage is required.
Pericardiectomy is primarily associated with severe constrictive pericarditis when definitive surgical treatment is indicated.
Recurrent Pericarditis
Recurrent pericarditis is one of the most challenging forms of the disease.
It occurs when symptoms and inflammatory activity return after an interval of improvement.
Patients may experience repeated episodes of:
- Chest pain
- Fever
- Elevated CRP
- ECG changes
- Pericardial effusion
- Reduced physical capacity
Recurrent disease can significantly affect quality of life because episodes may occur repeatedly over months or years.
The treatment strategy emphasizes controlling inflammation and preventing further attacks.
Colchicine plays an important role in reducing recurrence risk, while selected patients with refractory inflammatory recurrent disease may benefit from IL-1 inhibition.
Constrictive Pericarditis
Constrictive pericarditis occurs when chronic inflammation produces a thickened, fibrotic, and sometimes calcified pericardium that restricts normal cardiac filling.
The rigid pericardium prevents the ventricles from expanding normally during diastole.
Patients may develop:
- Progressive dyspnea
- Peripheral edema
- Ascites
- Elevated jugular venous pressure
- Fatigue
- Hepatomegaly
- Reduced exercise tolerance
The clinical picture can resemble right-sided heart failure.
Echocardiography, CT, CMR, and sometimes invasive hemodynamic assessment may be required to establish the diagnosis.
In selected patients with persistent, clinically significant constriction, pericardiectomy may be considered.
Importantly, not every patient with pericardial inflammation and transient constrictive physiology requires immediate surgery. Some inflammatory constrictive states may improve with appropriate medical treatment when the underlying inflammation is controlled. The modern ESC approach emphasizes careful differentiation between potentially reversible inflammatory constriction and established chronic constrictive disease.
Complications
Pericarditis can produce several complications.
Pericardial Effusion
Fluid may accumulate around the heart and range from a small clinically insignificant collection to a large symptomatic effusion.
Cardiac Tamponade
Tamponade occurs when increased intrapericardial pressure significantly compromises cardiac filling.
It is a medical emergency.
Recurrent Pericarditis
Repeated episodes can occur after the initial inflammatory episode has resolved.
Constrictive Pericarditis
Chronic inflammation can produce fibrosis and impaired ventricular filling.
Myocardial Involvement
Inflammation may extend into the myocardium, producing myopericarditis or perimyocarditis.
Arrhythmias
Arrhythmias can occur particularly when there is associated myocardial inflammation.
Hemodynamic Instability
Severe effusion, tamponade, myocarditis, or systemic infection can produce shock and organ dysfunction.
Pericarditis and Myocarditis
Pericarditis and myocarditis are closely related inflammatory disorders.
Pericarditis primarily involves the pericardial sac, while myocarditis primarily involves the cardiac muscle.
However, inflammation can involve both structures.
A patient with predominant pericardial symptoms but mild myocardial injury may be described as having myopericarditis, while predominant myocardial disease with associated pericardial inflammation may be classified differently depending on the clinical and imaging findings.
This distinction is clinically important because significant myocardial involvement may affect physical activity recommendations, monitoring, prognosis, and treatment.
The 2025 ESC guidelines emphasize that myocarditis and pericarditis exist along a spectrum rather than always representing completely separate diseases.
Pericarditis in Special Populations
Pericarditis in Children
Pericarditis can occur in children and adolescents.
The causes vary with age and clinical setting. Viral and inflammatory conditions are important considerations.
Children may have chest pain, fever, tachycardia, respiratory symptoms, or nonspecific complaints.
Because children may describe symptoms differently from adults, clinical assessment requires particular attention.
Pericarditis During Pregnancy
Pericarditis during pregnancy requires individualized assessment.
Drug selection must account for gestational age and maternal-fetal safety.
A pregnant patient with significant chest pain or suspected pericarditis should receive medical evaluation rather than self-treatment.
Pericarditis in Older Adults
Older patients may have less typical symptoms and a greater burden of comorbid disease.
Medication interactions, renal function, gastrointestinal risk, and cardiovascular disease must be considered carefully when selecting treatment.
Pericarditis in Immunocompromised Patients
Immunocompromised patients have a broader range of potential infectious and malignant causes.
A lower threshold for investigating specific etiologies may therefore be appropriate.
Physical Activity and Exercise
Physical activity is an important consideration during recovery.
During the acute inflammatory phase, physical activity is generally restricted because exercise may increase physiological stress and can be particularly concerning when myocardial involvement is present.
Return to normal exercise should not be based solely on the disappearance of pain.
Clinical remission, inflammatory markers, cardiac function, ECG findings, and the presence or absence of myocardial involvement may all influence the timing of return to activity.
The 2025 ESC guidance emphasizes an individualized approach to physical activity and return to work rather than applying a single rigid timeline to every patient.
Prognosis
The prognosis of pericarditis varies widely.
Many cases of uncomplicated acute pericarditis respond well to appropriate treatment and resolve without permanent cardiac damage.
The prognosis becomes more concerning when the disease is associated with:
- Cardiac tamponade
- Significant myocardial involvement
- Bacterial infection
- Tuberculosis
- Malignancy
- Recurrent inflammation
- Persistent inflammation
- Constrictive physiology
The underlying cause is therefore one of the most important determinants of outcome.
Patients with recurrent disease may experience substantial effects on quality of life even when mortality risk remains low.
Prevention of Recurrence
Preventing recurrence is an important part of pericarditis management.
Strategies include:
- Appropriate treatment of the initial inflammatory episode
- Use of colchicine when indicated
- Avoiding premature discontinuation of therapy
- Identifying and treating specific underlying causes
- Monitoring inflammatory activity
- Avoiding excessive physical exertion during active inflammation
- Careful follow-up in patients with recurrent disease
- Considering targeted therapy in selected refractory cases
Patient education is also important. Patients should understand that improvement in pain does not necessarily mean that the inflammatory process has completely resolved.
Patient Education
Patients should be advised to seek medical attention promptly if they develop:
- New or worsening chest pain
- Severe shortness of breath
- Fainting
- Marked weakness
- Palpitations with dizziness
- Persistent fever
- Rapid worsening of symptoms
- Swelling of the legs
- Symptoms suggestive of tamponade or another serious complication
Patients should also understand the importance of medication adherence and follow-up.
Self-treatment with NSAIDs, corticosteroids, or colchicine without medical assessment is inappropriate because these medications have important contraindications and interactions.
Practical Clinical Approach
A practical approach to a patient with suspected pericarditis begins with recognition of the characteristic symptom pattern.
A patient presenting with sharp, pleuritic, positional chest pain should undergo careful cardiovascular assessment.
The clinician should obtain an ECG, cardiac biomarkers, inflammatory markers, and appropriate imaging.
Echocardiography is particularly important for evaluating pericardial effusion and detecting evidence of tamponade.
If the diagnosis remains uncertain, or if myocardial or pericardial inflammation requires more detailed characterization, cardiovascular magnetic resonance can provide valuable information.
The next step is to determine whether the presentation is uncomplicated or high risk.
Patients with hemodynamic compromise, suspected bacterial infection, large effusion, tamponade, significant myocardial involvement, or other major risk features require more intensive evaluation and management.
For uncomplicated inflammatory disease, anti-inflammatory treatment combined with colchicine is central to modern therapy.
If a specific etiology is identified, treatment should be directed toward that cause.
For recurrent or refractory inflammatory disease, treatment may require specialist management and, in selected cases, targeted anti-IL-1 therapy.
Key Clinical Points
Pericarditis is an inflammatory disease of the pericardium that commonly presents with sharp, pleuritic and positional chest pain.
The pain is often worse when lying flat and improves when sitting upright or leaning forward.
A pericardial friction rub is a classic physical finding, although it may be transient.
Typical ECG findings include widespread ST-segment elevation and PR-segment depression.
Pericardial effusion can accompany pericarditis and may occasionally progress to cardiac tamponade.
Echocardiography is essential for detecting and assessing pericardial effusion and hemodynamic consequences.
CRP and other inflammatory markers can help establish and monitor inflammatory activity.
Troponin elevation suggests myocardial involvement and requires careful assessment for myopericarditis or alternative causes of myocardial injury.
Cardiac magnetic resonance is increasingly important for confirming and characterizing myocardial and pericardial inflammation.
Treatment of uncomplicated pericarditis generally involves an NSAID or aspirin together with colchicine when appropriate.
Corticosteroids have selected indications but are not generally preferred as routine first-line treatment when standard therapy is suitable.
Recurrent disease may require prolonged anti-inflammatory management and, in selected refractory cases, IL-1-targeted therapy.
Cardiac tamponade is a life-threatening complication requiring urgent recognition and appropriate drainage.
Constrictive pericarditis results from chronic pericardial scarring and may require surgical management in selected patients.
Modern management emphasizes identifying the underlying cause, assessing risk, using multimodality imaging when needed, controlling inflammation, preventing recurrence, and tailoring physical activity and follow-up to the individual patient.
.jpeg)
