What is acute pericarditis?

An acute inflammation of the pericardium, the serous membrane surrounding the heart, characterized by pleuritic chest pain and possible pericardial effusion.

What are the main causes of acute pericarditis?

The most common causes are viral infections (Coxsackie, Influenza), autoimmune diseases, neoplasms, uremia, post-infarction and certain drugs.

How is acute pericarditis recognized?

The most typical symptom is pleuritic chest pain. On auscultation, a pericardial friction rub is often present. The ECG shows typical four-stage changes.

How is acute pericarditis treated?

Treatment is based on NSAIDs, colchicine and, in selected cases, corticosteroids or antibiotics. Tamponade requires pericardiocentesis.

What complications can it cause?

Acute cardiac tamponade and, rarely, progression to chronic constrictive pericarditis or recurrences.

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Acute Pericarditis

Article written and reviewed by Dr Luca Moretti

Acute pericarditis is an inflammation of the pericardium, the serous membrane surrounding the heart, lasting less than two months. The etiology may 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 frequent and can complicate the clinical course.

Clinical presentation

The main symptom is chest pain, typically located in the left retrosternal area, radiating to the back and shoulders. The pain is pleuritic in nature, worsens with deep inspiration and supine position, and improves when sitting and leaning forward.

Fever of varying degree is often associated, sometimes accompanied by systemic symptoms such as:

Asthenia and general malaise.
Musculoskeletal pain.
Symptoms suggestive of concomitant infection (cough, diarrhea, arthralgias).

Dyspnea, present in about one third of patients, may indicate significant pericardial effusion, whereas orthopnea is a 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 recurrent laryngeal nerve involvement.

Physical examination

The most characteristic finding is the pericardial friction rub, a superficial, harsh and discontinuous sound, similar to leather rubbing. It is best appreciated with the patient sitting and the chest leaning forward. In large effusions, the rub may decrease or disappear, giving way to signs of cardiac tamponade:

Jugular vein distension.
Pulsus paradoxus (decrease in arterial pressure during inspiration).
Muffled heart sounds, due to the presence of pericardial fluid.

Diagnosis

The electrocardiogram (ECG) is a first-line examination and shows alterations evolving through four stages:

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

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 quantification of pericardial fluid and assessment of hemodynamic compromise.

In patients with significant effusion or overt cardiac tamponade, pericardiocentesis is indicated to drain the fluid and analyze it for infectious, neoplastic, or autoimmune etiology. The procedure is usually performed via the subxiphoid approach according to Marfan's technique.

Treatment

Treatment varies according to severity and etiology. In most cases, therapy is symptomatic and includes:

NSAIDs (ibuprofen, aspirin) for pain and inflammation control.
Colchicine, recommended to reduce the risk of recurrences.
Corticosteroids in resistant cases or autoimmune pericarditis (to be used with caution).
Antibiotics in case 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 the most severe cases, progression to constrictive pericarditis can impair ventricular filling, requiring pericardiectomy.

References

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