Pericarditis:
symptoms, warning signs and when to worry

Article written and reviewed by Dr Luca Moretti

The most characteristic symptom of pericarditis is chest pain that often worsens with a deep breath or when lying down and may lessen when sitting up or leaning forward. Fever, fatigue, palpitations and shortness of breath may also occur. The problem is that chest pain cannot be safely attributed to pericarditis solely on the basis of how it feels.
If the pain is new, severe or different from usual, or occurs together with significant shortness of breath, fainting, marked weakness, sweating, very low blood pressure or rapid deterioration, urgent assessment is required. If the presentation is compatible with a cardiac emergency, call 112 or 118.

Symptoms and signs that deserve particular attention include:

• persistent or severe chest pain;
• chest pain associated with significant shortness of breath;
• fainting or a feeling of impending loss of consciousness;
• sudden weakness, confusion or rapid deterioration in general condition;
• very low blood pressure, especially when associated with tachycardia;
• fever above 38 °C;
• development of a large pericardial effusion;
• lack of improvement despite prescribed treatment.

The pericarditis is an inflammation of the pericardium, the sac surrounding the heart. This guide does not replace the specialist discussion of the disease: it is intended to explain how pericarditis may present, which symptoms are more compatible with it and, above all, which situations should not be underestimated.

What symptoms can pericarditis cause?

The chest pain is the most frequent manifestation of acute pericarditis. In the classic form it is a sharp, stabbing or burning pain, often located behind the sternum or on the left side of the chest. It may worsen with deep inspiration, coughing, swallowing or when lying supine. Many people instead report improvement while sitting, especially when leaning slightly forward.
These features are useful for guiding suspicion but do not constitute proof. The pain may be less typical, duller or more pressure-like, and some people cannot clearly describe its relationship with position or breathing. For this reason, the symptom must always be interpreted together with the physical examination, electrocardiogram, blood tests and, when indicated, echocardiography or other imaging tests.

The fever may accompany the acute episode, especially in infectious forms or when there is a strong inflammatory response, but it is not present in every case. Fatigue, general malaise, reduced appetite and a sensation of a fast or irregular heartbeat may also occur.
The shortness of breath deserves particular attention. It may simply result from the fact that deep breathing worsens the pain, but it may also be associated with a pericardial effusion, myocardial involvement or, more rarely, hemodynamic compromise. Marked dyspnea, especially if it occurs at rest or worsens rapidly, should not simply be observed at home.

What pericarditis pain can feel like

Typical pericarditic pain is described as pleuritic and positional. "Pleuritic" means that it may worsen with deep respiratory movements, while "positional" means that its intensity may change depending on body position. The explanation relates to movement and friction of the inflamed surfaces and to the anatomical relationships of the pericardium with surrounding structures.
Improvement when leaning forward is well known, but it is not present in everyone. Likewise, pain that worsens when lying down is suggestive but not sufficient to make the diagnosis. Acute pericarditis can also produce electrocardiographic changes that, in some cases, enter the differential diagnosis with an acute coronary syndrome.

Pericarditis pain may radiate to the shoulder and trapezius region, but this finding is not exclusive either. A myocardial infarction, pulmonary embolism, aortic dissection and other diseases can present with chest pain and have very different consequences. For this reason, it is not safe to use a single feature of the pain at home to decide that it is "only" pericarditis. The practical distinction between the two conditions is discussed in the guide pericarditis pain or heart attack.

When pericarditis requires greater attention

Guidelines distinguish forms without high-risk features from those with findings associated with a greater probability of complications or a specific cause. The main red flags include fever above 38 °C, subacute onset with symptoms developing over several days, a large pericardial effusion, cardiac tamponade, and lack of response to aspirin or NSAIDs after at least one week of adequate treatment.
Conditions such as concomitant myocardial involvement, immunosuppression, trauma and oral anticoagulant therapy are also considered relevant. The presence of these factors does not automatically mean that pericarditis will have a severe course, but it changes the level of concern, the investigations needed and, in many cases, whether hospital management is appropriate.

The most urgent warning sign is the development of cardiac tamponade, a situation in which fluid in the pericardial sac exerts enough pressure to impair normal filling of the heart. It may present with significant dyspnea, tachycardia, hypotension, marked weakness, a feeling of faintness or loss of consciousness. The classic triad of textbook signs does not have to be present: especially in more slowly evolving forms, the picture may be less obvious.
Pain associated with elevated troponin may also indicate that the myocardium, as well as the pericardium, is involved. In this case the assessment changes because the problem is no longer isolated pericarditis.

What to do if symptoms compatible with pericarditis occur

If chest pain has occurred for the first time, it is not advisable to self-diagnose pericarditis on the basis of information read online or a previous episode. The initial assessment is intended first of all to exclude time-sensitive and potentially dangerous conditions. Medical history, examination, ECG, inflammatory markers and troponin are generally considered; echocardiography can identify an effusion and any hemodynamic consequences.
If symptoms are mild and a diagnosis of pericarditis has already been made, subsequent management should follow the plan established by the physician. Recurrence of pain during treatment tapering, high fever, increasing dyspnea or general deterioration deserves reassessment and should not be managed by independently increasing medication doses.

During the active phase, a reduction in physical activity is also recommended until clinical remission, with return depending on the individual clinical picture and any myocardial involvement. It is not useful to "test" the heart with exertion to see whether the pain returns.
In the event of significant chest pain, symptoms compatible with myocardial infarction, fainting, severe breathing difficulty or rapid deterioration, the priority is to contact the emergency medical system immediately and not drive yourself to the emergency department.

Frequently asked questions about pericarditis symptoms

What is the most typical symptom of pericarditis?
The most characteristic symptom is chest pain that is often sharp, tends to worsen with deep inspiration or when lying down, and may improve while sitting up or leaning forward. However, not all patients have the classic presentation.

Can pericarditis cause shortness of breath?
Yes. Dyspnea may be related to pain, a pericardial effusion or myocardial involvement. If it is significant or worsens rapidly, urgent assessment is required.

Does pericarditis always cause fever?
No. Fever may be present but is not required. A temperature above 38 °C is a higher-risk feature and requires more thorough assessment.

When does pericarditis pain require emergency-department assessment?
New or severe chest pain, especially when associated with shortness of breath, fainting, marked weakness, sweating, hypotension or rapid deterioration, requires urgent assessment.

Can pericarditis be distinguished from a heart attack by symptoms alone?
No. Some features may point in one direction, but there is overlap and diagnosis requires clinical assessment with appropriate tests.