Acute pericarditis typically presents with sharp pleuritic chest pain, exacerbated by the supine position and improved with leaning forward. Fever and myalgias may be present. On examination, a scratch-like friction rub is heard as parietal pericardium passes over epicardium. Friction rubs have been noted to evolve over a period of hours; the incidence of a friction rub in acute pericarditis has been reported to range from 35%-85%.
A variety of infections may be present as an underlying cause of pericarditis. When an infectious cause is identified, 90% are viral (most commonly coxsackievirus A or B, echovirus, Epstein-Barr virus, HIV, cytomegalovirus, or parvovirus B19). Viral pericarditis may also involve the myocardium, causing myopericarditis. The most common bacterial pathogens include Staphylococcus aureus, Streptococcus pneumonia, or, in developing countries, tuberculosis (see also bacterial pericarditis). Fungi such as Candida spp. and parasites such as Toxoplasma gondii also cause pericarditis.
Noninfectious causes include trauma, surgery, myocardial infarction, uremia, aortic dissection, myxedema, radiation, rheumatological conditions (including lupus, sarcoidosis, rheumatoid arthritis, and scleroderma), medications (including hydralazine, procainamide, methyldopa, phenytoin, and penicillin), and malignancy. Many cases are idiopathic.
Episodes of pericarditis are usually self-limited and respond well to medications unless high-risk features are seen (see Management Pearls). While not usually life-threatening, acute pericarditis can progress to cardiac tamponade or constrictive pericarditis in some complicated cases.
Recurrence is seen in about one-quarter to one-half of patients. Odds of recurrence can be decreased with colchicine therapy (see Therapy).
I31.9 – Disease of pericardium, unspecified
3238004 – Pericarditis
- Coronary artery disease (angina pectoris) – Classically presents as a substernal pressure with diaphoresis and nausea but no fever. Worse with exertion.
- Aortic dissection – Classically presents as tearing pain radiating to the back. At maximal intensity at its sudden onset.
- Pulmonary embolism – Classically a pleuritic chest pain and shortness of breath associated with tachycardia and desaturations.
- Gastroesophageal reflux disease – A burning retrosternal discomfort after eating. Worse with lying supine.
- Distinguishing acute pericarditis from STEMI and early repolarization is a diagnostic challenge:
- Ask about recent viral illness, look for PR depressions, ST elevations across nonanatomically contiguous leads, and ST:T ratio in V6 greater than 0.25 (all of which favors pericarditis).
- Look for an anatomic distribution of increasing convexity over repeated ECGs, or ST elevation in III>II, which favors STEMI.