Dr. Khalid is a physician, a researcher, a health writer, and holds a Ph.D. in clinical research.
Classification of Pericarditis
Pericarditis develops due to an accumulation of fluid inside the fibro-elastic/double-layered pericardial sac (1). The purulent, hemorrhagic, or serous nature of pericardial effusion triggers cardiac tamponade by challenging the diastolic filling process. Evidence-based medical literature recognizes the following types of pericarditis (2).
- Effusive-constrictive pericarditis
- Constrictive pericarditis
- Cardiac tamponade
- Pericardial effusion
- Recurrent pericarditis
- Chronic pericarditis
- Subacute pericarditis
- Acute pericarditis
The history of pericarditis patients includes the following (3).
- Left pericardial, substernal, and pleuritic type chest pain with spontaneous onset
- The pericarditis pain aggravates in the supine position and reduces in a forward-leaning position
- The pleuritic chest pain often radiates to the jaw, arms, neck, and ridge of the trapezius
- The cytokine storm due to inflammatory processes triggers myalgia, malaise, and fever
- Cardiac tamponade manifests with respiratory difficulty or shortness of breath
The following conditions/procedures increase the risk of pericarditis and its deleterious complications (2) (4).
- Previous history of varicella, mumps, measles, influenza, HIV/AIDS, hepatitis, and coxsackie viruses
- Autoimmune disorders
- Lung/breast cancers
- Radiation therapy
- Hodgkin’s disease
- Renal failure
- Chest trauma
- Pacemaker status
- Aortic dissection
- Acute myocardial infarction
- Dependence on drugs, including rifampicin, procainamide, phenytoin, penicillin, isoniazid, hydralazine, doxorubicin, and dantrolene
The medical examination concerning pericarditis reveals one or more of the following findings (2) (5).
- Tachycardia, tachypnea, pulsus paradoxus, jugular venous distension, and hypotension manifest with cardiac tamponade
- Pericardial friction rub transiently progresses in 1-3 phases due to consistent contact of the pericardial sac with the heart during ventricular/atrial systole and rapid ventricular filling
- A pericardial friction rub is usually felt across the left sternal border in forward-leaning and sitting positions during expiration
- Muffled heart sounds emanate due to cardiac tamponade and pericardial effusion
- Pleural effusions, identified with dullness across the thorax
The physician must investigate and rule out the following conditions/risk factors to affirm the diagnosis of pericarditis (6) (7).
- Pulmonary embolism
- D-dimer elevation
- Embolus on pulmonary angiogram
- Deep vein thrombosis
- Acute coronary syndrome with autonomic symptoms and radiating central chest discomfort/pain
- Pneumonia with productive cough, fever, and pleuritic type chest pain
- Reproduction of chest (wall) pain via palpation
- Elevation of localized/stinging chest (wall) pain with respiration
- Gastroesophageal reflux disease/acute gastritis symptoms including dysgeusia, epigastric/lower sternal pain, or burning (with a normal electrocardiogram)
- The co-occurrence of back pain with chest pain in a hemodynamically stable patient with aortic dissection
The following diagnostic interventions help evaluate pericarditis in various clinical scenarios (8) (9).
- The ST-segment elevation/T-wave amplitude ratio (0.25 or above) across V-6 ECG lead will affirm acute pericarditis
- Absence of myocardial infarction affirmed by the absence of Q-waves/reciprocal changes in a twelve-lead electrocardiogram
- ECG changes may correlate with superficial myocardial inflammation
- The appearance of isoelectric ST-segment, diffuse T-wave inversions, PR depression, or diffuse ST elevation
- The exclusion of cardiac tamponade warrants echocardiography
- Echocardiography findings concerning cardiac tamponade include the collapse of the right ventricle/atrium diastolic chamber
- The elevation in leukocyte count, erythrocyte sedimentation rate, and C-reactive protein strengthens the evidence for acute pericarditis
- The epicardial inflammation in pericarditis manifests with myocardial injury (affirmed by a marked elevation in cardiac troponins and creatine kinase)
- The recurrence of cardiac tamponade or failure of pericardiocentesis warrant subxiphoid pericardial biopsy/drainage for histological/cytological assessment
- Pleural fluid assessment (followed by thoracentesis) to investigate mycobacteria and adenosine deaminase
- The diagnostic management of purulent pericarditis relies on pericardiocentesis
- The assessment of mycobacteria, rheumatoid factor, and antinuclear antibodies is necessary to understand the causes of acute pericarditis (irresponsive to medical management)
- Magnetic resonance imaging and computed tomography help investigate inconclusive pericarditis
- Chest radiography guides the baseline assessment for pericarditis
The following evidence-based interventions support the medical management of pericarditis (10) (11) (8).
- The self-limiting manifestations of acute pericarditis usually require outpatient interventions
- The need for hospitalization may arise for the medical management of pericarditis patients with troponin-I elevation, myopericarditis, immune system compromise, history of injury, cardiac tamponade (affirmed by neck vein distension and hypotension), pericardial effusion, and pyrexia
- The replacement of NSAID therapy with 0.5mg colchicine (twice daily) may rapidly reduce the symptoms of patients with acute idiopathic/viral pericarditis
- The six-hourly administration of 300-800mg ibuprofen or 800mg aspirin until the resolution of pleural effusion may reduce pericardial friction rub, fever, and chest pain in the setting of pericarditis
- Regular monitoring of chronic constrictive pericarditis, cardiac tamponade, and pericardial effusion is the key to avoid fatal complications
- The adjuvant corticosteroid therapy may reduce the manifestations of idiopathic/uremic/auto-reactive/refractory recurrent pericarditis
- The treatment of malignant pericardial effusion relies on the intra-pericardial application of mitoxantrone
- Pericardiocentesis facilitates the diagnostic management of purulent pericarditis and therapeutic management of cardiac tamponade
1. Willner, D. A.; Goyal, A.; Grigorova, Y.; Kiel, J. Pericardial effusion. In StatPearls; StatPearls Publishing, 2021.
2. Dababneh, E.; Siddique, M. S. Pericarditis. In StatPearls; StatPearls Publishing, 2021.
3. Tingle , L. E.; Molina , D.; Calvert, C. W. Acute pericarditis. American Family Physician 2007, 76 (10), 1509-1514.
4 Andreis, A.; Imazio, M.; Casula, M.; Avondo, S.; Brucato, A. Recurrent pericarditis: an update on diagnosis and management. Intern Emerg Med 2021, 1-8.
5. Sagristà-Sauleda, J.; Mercé, A. S.; Soler-Soler, J. Diagnosis and management of pericardial effusion. World Journal of Cardiology 2011, 3 (5), 135-143.
6. Khandaker, M. H.; Espinosa, R. E.; Nishimura, R. A.; Sinak, L. J.; Hayes , S. N.; Melduni, R. M.; Oh, J. K. Pericardial Disease: Diagnosis and Management. Mayo Clin Proc. 2010, 85 (6), 572–593.
7. Vyas, V.; Goyal , A. Acute Pulmonary Embolism. In StatPearls; StatPearls Publishing, 2021.
8. Ismail, T. E. Acute pericarditis: Update on diagnosis and management. Clin Med 2020, 20 (1), 48-51.
9. Awan, A.; Tiruneh, F.; Wessley, P.; Khan , A.; Iftikhar, H.; Barned, S.; Larbi, D. Acute Pericarditis: Descriptive Study and Etiology Determination in a Predominantly African American Population. Cureus 2017, 9 (7).
10. Lentzsch, S.; Reichardt, P.; Gürtler, R.; Dörken, B. Intrapericardial Application of Mitoxantrone for Treatment of Malignant Pericardial Effusion. Oncology Research and Treatment 1994.
11. Musch, E.; Gremmler, B.; Nitsch, J.; Rieger, J.; Malek, M.; Chrissafidou, A. Intrapericardial instillation of mitoxantrone in palliative therapy of malignant pericardial effusion. Onkologie 2003, 26 (2), 135-139.
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2021 Dr Khalid Rahman