Pericarditis

Pericardial inflammation · all etiologies · complete doses + COPE/ICAP/AIRTRIP/RHAPSODY trials · Full Card

Symptoms / Associated Sx

• Sharp, pleuritic chest pain — worsens with inspiration, coughing, or lying flat; relieved by sitting upright and leaning forward (decompresses pericardium against sternum); onset over hours to days; may radiate to left shoulder or trapezius ridge (phrenic nerve irritation — pathognomonic for pericardial disease)

• Pericardial friction rub: scratchy, leathery, superficial sound; up to 3 components (systolic + early diastolic + presystolic atrial); best heard at LLSB with patient leaning forward in held exhalation; intermittent — repeated auscultation if suspected; pathognomonic when present but absent in up to 50% at any given moment

• Preceding viral upper respiratory infection 1–2 weeks prior (Coxsackievirus B most common); low-grade fever; malaise; myalgia

• Myopericarditis: pericarditis features + troponin elevation + may have ↓EF; cardiac MRI distinguishes from isolated myocarditis (subepicardial LGE = myocarditis; pericardial LGE = pericarditis; often both)

Neg

• Pt denies focal territorial ST elevation (inferior/anterior/lateral distribution) with reciprocal ST depression in mirror leads and focal wall motion abnormality on echo — argues against STEMI (pericarditis ECG: diffuse saddle-shaped STE in all leads except aVR and V1 which show reciprocal ST↓; no focal WMA on echo in pericarditis; PR depression in multiple leads — specific for pericarditis)

• Pt denies tearing/ripping back pain between shoulder blades with BP differential >20 mmHg between arms — argues against aortic dissection causing hemopericardium (Type A dissection can cause hemopericardium which mimics pericarditis clinically; CTA if dissection features present; anticoagulants worsen hemopericardium)

• Pt denies markedly elevated troponin with viral prodrome and diffuse non-territorial ECG changes without pleuritic quality or friction rub — argues against isolated myocarditis (myocarditis has higher troponin elevation, more global LV dysfunction, non-pericarditic ECG; cardiac MRI distinguishes: subepicardial/midmyocardial LGE = myocarditis; pericardial enhancement = pericarditis)

• Pt denies fever + purulent-appearing pericardial fluid + septic appearance without viral prodrome — argues against bacterial purulent pericarditis (purulent pericarditis: S. aureus/Streptococcus; high mortality; requires surgical drainage + IV antibiotics; low-grade fever + viral URI = viral/idiopathic, not purulent)

Social History (SHx)

• Recent viral URI (type, duration, severity); prior pericarditis episodes (number, treatment response, recurrence timing — predicts future recurrence risk); recent cardiac surgery (post-pericardiotomy syndrome — 10–40% incidence; weeks to months post-op); recent MI (Dressler syndrome Days 2–6 weeks; early pericarditis Days 1–2); CKD stage (uremic pericarditis — BUN >60 → hemodialysis resolves)

• Immunosuppression (HIV CD4 count, transplant, cancer chemotherapy — opportunistic causes); TB exposure/travel (Africa/Asia — most common worldwide etiology; purulent constrictive pericarditis); malignancy (lung, breast, lymphoma — malignant effusion); autoimmune disease (SLE, RA, SSc); medications (hydralazine [Apresoline], procainamide [Pronestyl], isoniazid [INH], dantrolene [Dantrium])

Main Etiology

• Idiopathic/viral (~90% in developed world): Coxsackievirus B (most common), echovirus, adenovirus, influenza, EBV, CMV, COVID-19; diagnosis of exclusion in most cases; self-limited in 70–90% with appropriate anti-inflammatory treatment

• Bacterial: purulent (S. aureus, Streptococcus pneumoniae, H. influenzae — direct spread from pneumonia or empyema; high mortality without surgical drainage); TB (most common worldwide; chronic; high risk of constrictive pericarditis; RIPE therapy + steroids ↓constriction)

• Post-cardiac injury: early post-MI pericarditis (Days 1–2 — adjacent inflamed pericardium; aspirin only; avoid NSAIDs/corticosteroids); Dressler syndrome (Days 2–6 weeks — immune-complex mediated; aspirin + colchicine [Colcrys]); post-pericardiotomy syndrome (weeks to months post-cardiac surgery — 10–40% incidence)

• Autoimmune/inflammatory: SLE (serositis; anti-dsDNA; may require hydroxychloroquine [Plaquenil]), RA, SSc, sarcoidosis (cardiac sarcoidosis — also AV block + VT); IgG4-related disease

• Uremic pericarditis: BUN >60 mg/dL + pericardial rub; no PR depression; responds dramatically to hemodialysis; NSAIDs/colchicine (Colcrys) less effective; avoid steroids

• Malignancy: lung, breast, lymphoma, mesothelioma; bloody effusion; diagnosis by pericardiocentesis fluid cytology; chemotherapy/radiation-related; poor prognosis

RF

• Recent viral URI (primary RF for idiopathic/viral); prior pericarditis (15–30% first recurrence; after 2nd recurrence risk rises substantially — identify recurrence-prone phenotype early); immunosuppression (opportunistic infections + impaired resolution); post-cardiac surgery or post-MI; CKD/uremia; TB exposure; malignancy; autoimmune disease (SLE highest pericarditis rate)

Data

• ECG serial — Stage I (most specific): (diffuse saddle-shaped [concave upward] ST elevation in all leads EXCEPT aVR and V1; PR depression in II, V4–V6 [most specific early finding]; PR elevation in aVR [reciprocal to PR depression]; Spodick sign = downsloping TP segment; absence of reciprocal ST depression except aVR/V1 = key distinction from STEMI; repeat ECG at 6–12h if equivocal; compare to prior)

• CRP + ESR (CRP preferred — rises faster and falls faster; markedly elevated in active pericarditis; CRP must normalize before stopping treatment; stopping aspirin or colchicine [Colcrys] with still-elevated CRP = very high recurrence risk; target CRP <1 mg/L before tapering)

• Troponin I/T (mild elevation in myopericarditis [overlap]; markedly elevated suggests myocarditis component → cardiac MRI mandatory; serial trend — rising troponin = ongoing myocardial involvement; isolated pericarditis without myocardial involvement has minimal or no troponin elevation)

• Echo TTE (pericardial effusion size: trivial/small/moderate/large; EF — myopericarditis: may be ↓; no focal WMA [distinguishes from STEMI]; tamponade physiology: RV diastolic collapse + IVC plethora + SBP variation >10 mmHg with respiration; pericardial thickening)

• CBC + BMP + LFTs (leukocytosis in bacterial pericarditis; Cr/BUN — uremic pericarditis threshold BUN >60; LFTs — colchicine [Colcrys] hepatotoxicity monitoring; electrolytes)

• ANA + anti-dsDNA + RF + anti-CCP + ANCA (if recurrent or autoimmune features); TSH (hypothyroidism — myxedema pericardial effusion); HIV serology if risk factors

• PPD/IGRA + CXR with PA/lateral (TB: hilar adenopathy; pleural effusion; calcifications in chronic; TB pericarditis: water-bottle heart [large effusion]; pericardial calcification in chronic constrictive)

• Blood cultures ×2 if purulent pericarditis suspected (S. aureus/Streptococcus; positive in 30–50% of purulent pericarditis)

• Cardiac MRI (pericardial LGE = active pericardial inflammation; myocardial LGE in subepicardial/midmyocardial non-ischemic distribution = myocarditis component; T1/T2 mapping for myocardial edema; most sensitive for identifying myocarditis extent; not required for uncomplicated first episode; recommended for recurrent/refractory or suspected myopericarditis)

DDx

STEMI (focal territorial STE + reciprocal ST↓ + focal WMA echo — cath lab; pericarditis: diffuse STE + no reciprocal changes + no WMA + PR depression) · NSTEMI/ACS (troponin rise/fall + ischemic sx + wall motion anomaly — pleuritic quality + PR depression + friction rub point to pericarditis) · PE/pleuritis (pleuritic CP + hypoxia + tachycardia + DVT signs — CT-PA; pericarditis: no hypoxia; diffuse ECG changes) · Aortic dissection (tearing back pain + BP differential — CTA; dissection can cause hemopericardium) · Myocarditis (viral prodrome + markedly elevated troponin + reduced EF + cardiac MRI subepicardial LGE — no friction rub; no PR depression)

Home Meds

• Hold: non-aspirin NSAIDs (ibuprofen [Advil]/naproxen [Aleve]/indomethacin [Indocin]) post-MI pericarditis — ↑scar thinning → ↑free wall rupture; corticosteroids if currently on (taper slowly — abrupt stop → rebound; only use if NSAID/colchicine failure; corticosteroids ↑recurrence rate); anticoagulants (warfarin [Coumadin]/DOACs — ↑hemorrhagic pericarditis risk; discuss with cardiology; hold if significant effusion on echo

• Switch to: aspirin (Bayer) 750–1000 mg PO TID for pericarditis pain (not NSAID); add colchicine (Colcrys) 0.5 mg PO BID; gastroprotection: omeprazole (Prilosec) 20 mg PO daily

Plan

• Confirm diagnosis (2 of 4 criteria): (1) pleuritic pericarditic chest pain; (2) pericardial friction rub; (3) diffuse saddle ST elevation or PR depression on ECG; (4) new pericardial effusion on echo; if only 1 criterion + typical presentation + CRP elevated → treat as probable pericarditis

• First-line treatment (COPE 2005 + ICAP 2013, NEJM):

  • Aspirin (Bayer/Ecotrin) 750–1000 mg PO TID ×2 weeks → taper by 250 mg every 1–2 weeks (total duration 4–6 weeks); preferred over NSAIDs in post-MI pericarditis (NSAIDs impair scar healing → ↑free wall rupture)

  • Ibuprofen (Advil/Motrin) 600–800 mg PO TID ×2 weeks → taper over 4 weeks (preferred alternative to aspirin in non-post-MI pericarditis; better GI tolerability than indomethacin); always with gastroprotection (omeprazole [Prilosec] 20 mg PO daily)

  • Indomethacin (Indocin) 25–50 mg PO TID ×2 weeks → taper (more GI toxicity; avoid in elderly; effective anti-inflammatory)

  • Colchicine (Colcrys) 0.5 mg PO BID (≥70 kg) or 0.5 mg PO daily (<70 kg) ×3 months (ICAP 2013: ↓recurrence 50% [11.7% vs 22.4%]; ↓incessant pericarditis 50%; no loading dose required; GI side effects: nausea/diarrhea — take with food; reduce to 0.5 mg daily if GI intolerant; avoid CrCl <30 or severe hepatic disease; avoid with CYP3A4 inhibitors: clarithromycin [Biaxin], ketoconazole — ↑colchicine levels → neuromuscular toxicity)

• Activity restriction — mandatory and duration-dependent on CRP: restrict strenuous physical activity until ALL of: CRP normal (<1 mg/L), complete symptom resolution, normal ECG, normal echo; for athletes: formal cardiology clearance before return to sport; typical duration 3–6 months for athletes; non-athletes: avoid moderate-vigorous exertion during symptomatic phase and until CRP normalizes | Premature return to activity while CRP elevated is the single most common trigger for recurrence — reinforce at every visit

• Post-MI pericarditis — aspirin only: aspirin (Bayer) 650 mg PO q4–6h ×2 weeks (post-MI: Dressler syndrome or early pericarditis Days 2–6); do NOT use other NSAIDs (ibuprofen [Advil]/naproxen [Aleve]) or corticosteroids — impair infarct scar healing → ↑free wall rupture risk; add colchicine (Colcrys) 0.5 mg PO BID ×3 months

• Corticosteroids (low-dose, last resort): prednisone (Deltasone) 0.2–0.5 mg/kg/day PO (CORE 2015: low-dose steroids comparable to full-dose but ↑recurrence vs ibuprofen [Advil] as first-line; use ONLY if: NSAID + colchicine [Colcrys] failure or contraindication [renal failure/GI]; autoimmune/connective tissue disease; uremic pericarditis unresponsive to hemodialysis; tuberculous pericarditis); start colchicine (Colcrys) simultaneously; slow taper over months guided by CRP; never taper without colchicine (Colcrys) coverage

• Recurrent pericarditis management:

  • 1st recurrence: full course aspirin/NSAID + colchicine (Colcrys) ×6 months

  • Colchicine-resistant recurrence: anakinra (Kineret) 100 mg SQ daily ×8–12 weeks (AIRTRIP 2016, NEJM: ↓recurrence 87% vs placebo; IL-1 inhibitor; screening for TB/hepatitis B before starting)

  • FDA-approved for recurrent pericarditis: rilonacept (Arcalyst) 320 mg SQ loading → 160 mg SQ weekly (RHAPSODY 2021: ↓recurrence 99% vs placebo during treatment; Class I ACC/AHA 2022 for recurrent colchicine-resistant pericarditis)

  • Pericardiectomy (surgical): for truly refractory recurrent pericarditis (>3 recurrences, failed all medical therapies); not curative for effusions; high-volume pericardial disease center

• Specific etiologies:

  • Purulent bacterial pericarditis: blood cultures ×2 → broad-spectrum antibiotics: vancomycin (Vancocin) 25–30 mg/kg IV q8–12h + piperacillin/tazobactam (Zosyn) 4.5 g IV q6h; surgical pericardial drainage (pericardiocentesis alone inadequate for thick purulent fluid; subxiphoid pericardiotomy or video-assisted thoracoscopic drainage)

  • TB pericarditis: RIPE therapy (rifampin [Rifadin] 600 mg + isoniazid [INH] 300 mg + pyrazinamide [PZA] 25 mg/kg + ethambutol [Myambutol] 15 mg/kg PO daily ×2 months then RH ×4 months) + prednisolone (Deltasone) 1 mg/kg/day PO ×6 weeks → taper (↓constrictive pericarditis risk and ↓mortality)

  • Uremic pericarditis: intensify hemodialysis (increase to daily sessions) — CRP and effusion resolve within 1–2 weeks; NSAIDs and colchicine (Colcrys) less effective; NSAIDs worsen renal function

  • Autoimmune (SLE/RA): treat underlying disease; hydroxychloroquine (Plaquenil) for SLE pericarditis; low-dose corticosteroids if needed

• PT/OT eval and treat — strict activity restriction during acute phase; reassess functional capacity at 6 weeks; formal return-to-exercise protocol guided by CRP normalization

• Trend daily/weekly: CRP weekly (the primary treatment guide — must normalize before stopping therapy; premature discontinuation when CRP still elevated is the most common cause of recurrence); ECG serial (stage progression, resolution); echo (effusion size trend — enlarging = tamponade risk); troponin if elevated at presentation (normalize before activity); fever curve (bacterial pericarditis — fever should ↓within 48h of antibiotics)

• Escalation triggers: new large effusion or hemodynamic compromise (Beck triad + pulsus paradoxus >10 mmHg) → pericardiocentesis (see PericardialEffusion card) · purulent/bacterial pericarditis → vancomycin (Vancocin) + Zosyn + surgical drainage urgently · myopericarditis with EF ↓<50% → cardiology + activity restriction + cardiac MRI + avoid exercise · TB pericarditis → RIPE therapy + prednisolone (Deltasone) · recurrent colchicine-resistant → anakinra (Kineret) or rilonacept (Arcalyst) · post-pericardiotomy syndrome unresponsive → prednisolone (Deltasone) 0.5 mg/kg/day

• Discharge: aspirin (Bayer) 750–1000 mg PO TID with taper plan (reduce by 250 mg every 1–2 weeks; total 4–6 weeks) + colchicine (Colcrys) 0.5 mg PO BID ×3 months (first episode); gastroprotection: omeprazole (Prilosec) 20 mg PO daily; strict activity restriction (written instructions: NO exercise until CRP <1 mg/L + symptom-free — provide specific CRP target number in discharge paperwork); no alcohol with colchicine (Colcrys) (↑hepatotoxicity); cardiology f/u 2–4 weeks with repeat CRP; return precautions: worsening chest pain + dyspnea + new fever → ED immediately

⚠ Red Flags

• NSAIDs or corticosteroids in post-MI pericarditis (Dressler syndrome or early pericarditis Days 1–6 post-STEMI) → impair infarct scar healing → ↑free wall rupture risk; aspirin (Bayer) is the ONLY appropriate anti-inflammatory in this setting; this is a critical and tested distinction

• Stopping aspirin or colchicine (Colcrys) while CRP still elevated → recurrence; CRP normalization is the mandatory endpoint before tapering; premature discontinuation is the single most common modifiable cause of recurrent pericarditis

• Corticosteroids as first-line in idiopathic pericarditis → CORE trial: steroids ↑recurrence rate vs NSAID-based therapy; use only as second-line or for specific indications (autoimmune, uremic, TB)

• Tamponade developing in untreated large effusion → Beck triad (JVD + hypotension + muffled heart sounds) + pulsus paradoxus >10 mmHg → pericardiocentesis immediately; any effusion >20 mm on echo warrants daily monitoring

• Purulent pericarditis missed as viral → S. aureus purulent pericarditis has >30% mortality; fever + elevated WBC + septic appearance + pericardial rub = purulent until proven otherwise; surgical drainage required (not pericardiocentesis alone)

Senior IM Resident Pearls

• 4 diagnostic criteria (≥2 required): (1) pleuritic pericarditic chest pain; (2) friction rub; (3) diffuse saddle ST elevation or PR depression on ECG; (4) new pericardial effusion on echo; PR depression in II + V4–V6 is the most specific early ECG finding (present before STE in some cases); Spodick sign (downsloping TP segment) is a more subtle early marker

• ICAP trial (2013, NEJM): colchicine (Colcrys) 0.5 mg BID + aspirin vs aspirin alone → ↓recurrence 50% (11.7% vs 22.4%); ↓incessant pericarditis 50%; colchicine (Colcrys) should be added to every first episode of pericarditis; duration 3 months for first episode, 6 months for recurrent

• RHAPSODY trial (2021, NEJM): rilonacept (Arcalyst) — IL-1α/β inhibitor — vs placebo in recurrent colchicine-resistant pericarditis → ↓recurrence 99% during treatment period; FDA-approved 2021; Class I indication for recurrent pericarditis; consider in any patient with ≥2 recurrences on colchicine (Colcrys)

• CRP normalization is the only safe endpoint for stopping treatment: patients who stop aspirin + colchicine (Colcrys) while CRP still elevated have dramatically higher recurrence rates; always obtain CRP at every follow-up visit; write the target (CRP <1 mg/L) on discharge instructions and communicate it explicitly to the patient

• Post-MI pericarditis — aspirin only: Dressler syndrome (immune-complex mediated; Days 2–6 weeks post-MI) and early pericarditis (Days 1–2 post-MI) require aspirin (Bayer) 650 mg PO q4–6h; ibuprofen and indomethacin thin the infarct scar and ↑free wall rupture risk; corticosteroids also worsen scar healing; this is a board question and a clinical trap

• Common mistake — premature return to physical activity: pericarditis patients (especially young athletes) who feel better after 1–2 weeks often return to exercise; CRP is still elevated subclinically even when symptoms resolve; premature exertion → inflammation flare → recurrence; the rule is CRP <1 mg/L + symptom-free + normal echo + normal ECG before ANY return to exercise, regardless of how the patient feels