Pericarditis: Symptoms, Types, Causes and Treatment

Pericarditis, the inflammation of the pericardium (the protective sac surrounding the heart), can affect anyone. While it’s often a benign and self-limited condition, it can sometimes lead to serious complications and even signal underlying systemic diseases. Understanding its symptoms, types, causes, and evidence-based treatments helps patients and healthcare providers recognize and manage this complex disorder more effectively.

Symptoms of Pericarditis

Pericarditis most often announces itself with chest pain, but its symptoms can overlap with other heart and lung conditions, making awareness crucial. Recognizing these signs early can help ensure a prompt diagnosis and appropriate care.

Symptom	Description	Frequency/Significance	Source
Chest Pain	Sharp, retrosternal, pleuritic	Most common, classic presentation	1 3 4
Shortness of Breath	Difficulty breathing, especially lying down	Common, especially with effusion	1 4
Pericardial Rub	Scratchy heart sound on exam	Diagnostic clue, but not always present	1 4
Fever	Elevated body temperature	Frequent in infectious cases	2 5 10
Prodromal Symptoms	Diarrhea, sore throat, chills, cough	Predict myocardial involvement	2
Fatigue	General malaise, weakness	Non-specific, can be present	4 8
Pericardial Effusion	Fluid around the heart	May cause tamponade, dyspnea	4 8 11

Table 1: Key Symptoms

Classic Chest Pain

• Sharp, stabbing pain in the center or left side of the chest is the hallmark of pericarditis.
• The pain typically worsens with deep breaths, coughing, or lying flat and improves when sitting up or leaning forward 1 3 4.
• Unlike the crushing pain of a heart attack, pericarditis pain is often pleuritic (related to breathing).

Additional Symptoms

• Shortness of breath can occur, especially if fluid accumulates in the pericardial space (pericardial effusion) 4.
• Fever is more common in infectious or purulent (pus-forming) cases and may accompany chills 2 5 10.
• Fatigue and general malaise are less specific but often present, particularly in subacute or chronic cases 4 8.
• Pericardial friction rub is a scratchy, grating sound heard with a stethoscope, caused by inflamed pericardial layers rubbing together; it is highly specific but not always present 1 4.

Prodromal and Warning Signs

• Diarrhea, sore throat, and fever as prodromal symptoms can predict a higher risk of myocardial involvement (myopericarditis), which may lead to more severe complications like left ventricular dysfunction or cardiogenic shock 2.
• Pericardial effusion may develop, sometimes leading to cardiac tamponade (compression of the heart by fluid), which can be life-threatening and manifests as severe shortness of breath, low blood pressure, and fainting 4 11.

Types of Pericarditis

Pericarditis is not a one-size-fits-all diagnosis. It comes in several forms, each with its own clinical course and management considerations. Understanding the different types ensures appropriate and timely therapy.

Type	Main Features	Clinical Course/Prognosis	Source
Acute Pericarditis	Sudden onset, lasts <4-6 weeks	Usually self-limited	1 4 8 14
Incessant Pericarditis	Lasts >4-6 weeks without symptom-free interval	May require prolonged therapy	4 14
Recurrent Pericarditis	Symptoms return after 4-6 weeks of remission	Risk of repeated episodes	4 7 8 14
Constrictive Pericarditis	Stiffened pericardium impairs heart filling	May lead to heart failure, needs surgery	6 13
Purulent Pericarditis	Bacterial, pus in pericardial sac	Acute, high mortality if untreated	5 10
Tuberculous Pericarditis	Caused by tuberculosis	Common in endemic areas, chronic	5 10 13
Myopericarditis	Inflammation involves pericardium and myocardium	May cause arrhythmia, LV dysfunction	2 3 4 11

Table 2: Types of Pericarditis

Acute and Chronic Variants

• Acute pericarditis is the most common form, characterized by rapid onset of symptoms. It generally responds well to anti-inflammatory treatment and resolves within weeks 1 4 8 14.
• Incessant pericarditis is persistent, with symptoms lasting beyond 4-6 weeks without a symptom-free interval.
• Recurrent pericarditis features repeated flare-ups after apparent resolution. This type is more likely if initial treatment is inadequate or discontinued too soon 4 7 8 14.

Complicated Forms

• Constrictive pericarditis arises when chronic inflammation leads to scarring and thickening of the pericardium, restricting the heart’s ability to fill with blood. This can cause severe right-sided heart failure and often requires surgical removal of the pericardium (pericardiectomy) 6 13.
• Purulent pericarditis is a medical emergency, caused by bacterial infection and accumulation of pus. Without urgent treatment, it is almost always fatal 5.
• Tuberculous pericarditis is more common in immunocompromised individuals and in regions with high rates of tuberculosis; it can lead to constriction and chronic complications 5 10 13.

Myopericarditis

• Myopericarditis refers to cases where there is inflammation of both the pericardium and the adjacent heart muscle (myocardium). This variant is associated with higher risk of arrhythmias, heart failure, and shock, particularly if prodromal symptoms like diarrhea and sore throat are present 2 3 4 11.

Causes of Pericarditis

The triggers of pericardial inflammation are diverse, ranging from infections to autoimmune diseases, cancers, and even medical interventions. In many cases, the cause remains elusive, but ongoing research continues to shed light on underlying mechanisms.

Cause	Examples/Notes	Prevalence/Significance	Source
Idiopathic	No clear cause; presumed viral	80–90% in developed countries	8 9 14
Viral	Coxsackievirus, influenza, SARS-CoV-2, HIV	Most common identified etiology	3 10 11
Bacterial	Staphylococcus, Streptococcus, TB, M. avium	Severe, less common	5 10
Tuberculous	Mycobacterium tuberculosis	Common in endemic areas	5 10 13
Autoimmune	Systemic lupus, rheumatoid arthritis	May signal underlying disease	4 8 9
Post-injury	Post-MI (Dressler’s), post-surgery, trauma	Significant in hospital cases	9
Malignancy	Lung, breast, lymphoma	May be first sign of cancer	4 9
Other	Uremia, radiation, drugs, vaccine-related	Variable, rare	3 4 7

Table 3: Causes of Pericarditis

Idiopathic and Infectious

• Idiopathic (unknown cause) pericarditis is most common, especially in developed countries. Most of these cases are presumed to be viral in origin, but a specific virus is rarely identified 8 9 14.
• Viral infections are the leading identifiable cause. Coxsackievirus, echovirus, influenza, HIV, and more recently SARS-CoV-2 (COVID-19) are implicated. Influenza A is more frequently associated with pericarditis and myopericarditis than influenza B 3 10 11.
• Bacterial pericarditis is less common but far more dangerous. Staphylococcus, Streptococcus, and tuberculosis are the main culprits. In immunocompromised patients, organisms like Mycobacterium avium are also significant 5 10.

Non-Infectious and Special Causes

• Autoimmune and systemic inflammatory disorders such as lupus, rheumatoid arthritis, and vasculitis can cause pericarditis as an initial or ongoing manifestation 4 8 9.
• Post-injury pericarditis (also known as post-cardiac injury or Dressler’s syndrome) can develop after heart surgery, heart attack, or chest trauma 9.
• Malignancy can directly invade the pericardium or provoke inflammation as a paraneoplastic phenomenon. Lung and breast cancers, as well as lymphomas, are most commonly involved 4 9.
• Other causes include chronic kidney disease (uremia), radiation therapy, certain medications, and, rarely, as an adverse reaction to vaccines (notably after COVID-19 mRNA vaccination, but the risk is much higher with actual infection than vaccination) 3 4 7.

Treatment of Pericarditis

Effective management depends on the cause and severity of the pericarditis, as well as the presence of complications. Most cases respond well to medical therapy, but some require advanced interventions.

Treatment	Indications/Use	Key Notes	Source
NSAIDs	First-line for most idiopathic/viral cases	Aspirin, ibuprofen; manage inflammation/pain	3 8 12 14
Colchicine	Adjunct to NSAIDs, lowers recurrence	Use for initial and recurrent pericarditis	3 8 14
Corticosteroids	Second-line; refractory/severe cases	Risk of recurrence with early use	3 8 15
Antibiotics	Bacterial or purulent pericarditis	IV therapy, urgent drainage if needed	5 10
Antitubercular Rx	Tuberculous pericarditis	Multi-drug regimen, add steroids sometimes	5 10 13
Pericardiocentesis	Large effusions, tamponade, diagnosis	Emergency in tamponade	5 10 13
Pericardiectomy	Constrictive or refractory pericarditis	Surgical removal of pericardium	6 13
IL-1 Inhibitors	Recurrent, refractory cases	For autoinflammatory/relapsing forms	7 15

Table 4: Treatment Approaches

Medical Therapy

• NSAIDs (such as aspirin or ibuprofen) are the cornerstone of therapy for most acute and idiopathic/viral pericarditis. They reduce inflammation and pain 3 8 12 14.
  • High-dose regimens are used initially and tapered over weeks.
  • Outpatient management is safe for low-risk patients without poor prognostic features (e.g., fever >38°C, large effusion, immunosuppression) 12.
• Colchicine is routinely added to NSAID therapy to reduce symptom duration and dramatically lower the risk of recurrence, both in the initial episode and in relapses 3 8 14.
• Corticosteroids are reserved for patients who cannot tolerate NSAIDs/colchicine or have refractory/severe disease. However, early use increases recurrence risk and should be avoided unless necessary 3 8 15.
• IL-1 inhibitors (such as anakinra) are emerging as effective options for recurrent, autoinflammatory forms of pericarditis 7 15.

Treating Specific Causes

• Bacterial (purulent) pericarditis requires immediate IV antibiotics and urgent pericardial drainage. Mortality remains high even with treatment 5 10.
• Tuberculous pericarditis is managed with multi-drug anti-TB regimens and often adjunctive corticosteroids to reduce complications; pericardiectomy may be needed if constriction develops 5 10 13.
• Pericardiocentesis is essential for cardiac tamponade and may be required to diagnose or relieve large effusions 5 10 13.
• Pericardiectomy (surgical removal of the pericardium) is the definitive treatment for constrictive pericarditis and some refractory recurrent forms 6 13.

Preventing Recurrence and Complications

• Colchicine is highly effective in reducing recurrences 8 14.
• Close monitoring is required for high-risk patients (poor prognostic features, large effusions, immunosuppression) 8 12.
• Risk factor modification (e.g., treating underlying autoimmune or cancerous causes) is crucial for long-term management 4 8 9.

Conclusion

Pericarditis is a multifaceted condition with a wide spectrum of presentations, causes, and treatments. Most cases are mild and respond to anti-inflammatory therapy, but some can progress to life-threatening complications. Awareness and understanding of its symptoms, types, causes, and current treatment strategies are essential for optimal patient outcomes.

Key Takeaways:

• Symptoms: Chest pain, shortness of breath, fever, and pericardial rub are common; prodromal symptoms can indicate severe forms 1 2 3 4.
• Types: Acute, recurrent, constrictive, purulent, and myopericarditis each have distinct features and management needs 4 5 6 7 8 11.
• Causes: Idiopathic/viral are most common; bacterial, tuberculous, autoimmune, malignancy, and post-injury causes are less frequent but important 3 5 8 9 10 13.
• Treatment: NSAIDs and colchicine are first-line; specific treatments are used for bacterial, tuberculous, and constrictive cases; surgery is reserved for refractory or complicated disease 3 5 6 8 13 14 15.

By staying informed and vigilant, healthcare providers and patients can work together to ensure prompt diagnosis, effective treatment, and prevention of complications in pericarditis.