Acute pericarditis is inflammation of the sac around the heart, most often after a viral infection, though it can follow a heart attack, surgery, kidney failure or autoimmune disease. It usually settles with anti-inflammatory treatment, but fluid can build up and squeeze the heart.
Key symptoms
- Sharp chest pain that worsens lying flat or breathing in
- Pain that eases when sitting up and leaning forward
- Pain that may spread to the top of the shoulder
- Fever or a recent cold or flu-like illness
- Shortness of breath
What you find on exam
- Pericardial friction rub: a scratchy sound at the left lower sternal border, best heard leaning forward
- Fever and fast heart rate
- Check for tamponade: low blood pressure, distended neck veins, pulsus paradoxus
- Muffled heart sounds if a large effusion is present
Tests
- ECG: widespread ST elevation with PR depression
- Troponin to look for heart muscle involvement (myopericarditis)
- Echocardiogram to look for an effusion
- CRP, blood count, kidney function and chest X-ray
Treatment basics
- High-dose NSAID such as ibuprofen, or aspirin, tapered over weeks
- Colchicine for 3 months to lower the chance of recurrence
- No strenuous exercise until symptoms and markers settle
- Admit high-risk patients: fever above 38 C, large effusion, raised troponin, no response to NSAIDs
- Drain the fluid (pericardiocentesis) if tamponade develops
Red flags
- Low blood pressure with distended neck veins
- Fever with a large effusion, or no improvement after a week of treatment
- Raised troponin or new heart failure
Practice it in Making Synapses
Making Synapses cases
Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.