AKT · Cardiovascular/Pericardium

Acute pericarditis

Inflammation of the pericardium — viral/idiopathic, post-MI (Dressler), uraemic, autoimmune, TB

Overview

Inflammation of the pericardial sac, usually viral or idiopathic. The classic picture is sharp pleuritic chest pain relieved by sitting forward, a pericardial friction rub, and widespread saddle-shaped ST elevation with PR depression. Treated with NSAIDs plus colchicine; the danger is progression to a significant effusion and tamponade.

Recognise

Sharp, pleuritic, central chest pain RELIEVED by sitting forward and worse lying flat/on inspiration
Pericardial friction rub; low-grade fever; recent viral illness
ECG: widespread (saddle-shaped) concave ST elevation with PR depression (and reciprocal changes in aVR); not territorial like STEMI

Red flags

Features of tamponade (raised JVP, hypotension, muffled heart sounds, pulsus paradoxus) → urgent echo ± pericardiocentesis
Large effusion, fever >38°C, subacute onset, immunosuppression, anticoagulation or failure to respond → high-risk, admit and investigate

Differentials & how to tell them apart

STEMIterritorial ST elevation with reciprocal change and troponin rise; not relieved by leaning forward

Myocarditis / myopericarditisraised troponin, ventricular dysfunction — overlapping

Pulmonary embolism / pleurisypleuritic pain with hypoxia/respiratory cause

Aortic dissectiontearing pain to the back, pulse/BP asymmetry

Acute pericarditis — widespread saddle-shaped ST elevation with PR depression (ECG)
James Heilman, MD / CC BY-SA 3.0 — Wikimedia Commons

Investigations

ECG (widespread saddle ST elevation, PR depression); troponin (raised suggests myopericarditis); inflammatory markers; echo (effusion); CXR; identify the cause (viral, uraemia [U&Es], autoimmune, TB, post-MI).

Management

NSAID + colchicine; treat the cause; restrict exercise

1Diagnose clinically/ECG and assess risk; identify the cause. First-line = an NSAID plus colchicine, with exercise restriction.Gate: Signs of tamponade or a large effusion → urgent echo and pericardiocentesis — don't just treat the inflammation.
2High-risk features (fever, large effusion, immunosuppression, anticoagulation, failure to respond) → admit and investigate the cause; reserve corticosteroids for specific causes or treatment failure (they raise recurrence).

NSAID (ibuprofen/aspirin) + colchicine — first-line combination; colchicine reduces recurrence; gastroprotection with the NSAID

Restrict strenuous exercise until resolved — especially if myopericarditis

Corticosteroids — only for specific causes (autoimmune, uraemic) or NSAID/colchicine failure — they increase recurrence

Treat the cause — dialysis for uraemic, anti-TB therapy, treat autoimmune disease

Key points

Sharp pleuritic chest pain relieved by sitting forward + friction rub + WIDESPREAD saddle ST elevation with PR depression = pericarditis → NSAID + colchicine. Watch for tamponade (raised JVP, hypotension, muffled sounds, pulsus paradoxus). Post-MI weeks later = Dressler's.

Monitor & prognosis

Symptom resolution, inflammatory markers, repeat echo for effusion.

Most viral/idiopathic cases resolve; recurrence reduced by colchicine.

Source: ESC pericardial disease guideline; cross-ref acute_care