Acute Pericarditis

Acute pericarditis is an inflammation of the pericardium, the serous membrane surrounding the heart, lasting less than two months. The etiology can be:

• Infectious (viral, bacterial, tuberculous, fungal).
• Autoimmune (SLE, rheumatoid arthritis, scleroderma).
• Neoplastic (pulmonary metastases, lymphomas, primary pericardial tumors).
• Idiopathic (unknown cause, often suspected viral origin).

The recurrent form is common and may complicate the clinical course.

Clinical Presentation

The main symptom is chest pain, localized in the left retrosternal area with radiation to the back and shoulders. The pain is pleuritic in nature, worsens with deep inspiration and the supine position, and is relieved by sitting up and leaning forward.

Fever of varying degrees is frequently associated, sometimes accompanied by systemic symptoms such as:

• Fatigue and general malaise.
• Musculoskeletal pain.
• Symptoms suggestive of concomitant infection (cough, diarrhea, arthralgia).

Dyspnea, present in about one-third of patients, may indicate a significant pericardial effusion, while orthopnea is a warning sign of possible cardiac tamponade.

When the inflammatory process involves adjacent structures, symptoms of mediastinal compression may occur:

• Dysphagia, due to esophageal involvement.
• Cough and dyspnea, due to airway compression.
• Persistent hiccups, due to phrenic nerve irritation.
• Dysphonia, due to involvement of the recurrent laryngeal nerve.

Physical Examination

The most characteristic finding is the pericardial friction rub, a superficial, rough, and discontinuous sound, resembling a leather-on-leather friction. It is best appreciated with the patient sitting up and leaning forward. In large effusions, the rub may diminish or disappear, giving way to signs of cardiac tamponade:

• Jugular vein distension.
• Pulsus paradoxus (a drop in blood pressure during inspiration).
• Muffled heart sounds, due to the presence of pericardial fluid.

Diagnosis

Electrocardiogram (ECG) is a first-line test and shows changes evolving in four stages:

• Stage 1: diffuse ST-segment elevation and PR-segment depression.
• Stage 2: normalization of the ST segment.
• Stage 3: diffuse T-wave inversion.
• Stage 4: gradual normalization of the T wave.

The chest X-ray, generally normal in mild cases, may reveal an enlarged cardiac silhouette in massive effusions, giving the heart a "flask-shaped" appearance. Echocardiography is the gold standard for diagnosis, allowing the assessment of pericardial fluid volume and possible hemodynamic compromise.

In patients with a large effusion or overt cardiac tamponade, pericardiocentesis is indicated, allowing fluid drainage and analysis to identify an infectious, neoplastic, or autoimmune etiology. The procedure is typically performed via a subxiphoid approach using Marfan’s technique.

Treatment

The treatment depends on severity and etiology. In most cases, therapy is symptomatic and includes:

• NSAIDs (ibuprofen, aspirin) for pain and inflammation control.
• Colchicine, recommended to reduce recurrence risk.
• Corticosteroids in refractory cases or autoimmune pericarditis (used cautiously).
• Antibiotics in cases of bacterial pericarditis.

Prognosis

Acute pericarditis generally has a favorable course, with complete resolution within a few weeks. However, recurrences are common, with an incidence of 20-30%, especially in patients not treated with colchicine. In severe cases, progression to constrictive pericarditis may impair ventricular filling, necessitating pericardiectomy.

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