ICU · Cardiovascular
Acute pericarditis
Also known as Acute pericarditis · Pericardial friction rub · Post-cardiac injury syndrome · Dressler syndrome
Acute pericarditis is inflammation of the pericardium. Causes: viral (1 — coxsackie, echovirus), idiopathic, post-MI (Dressler syndrome — autoimmune, weeks after MI), post-pericardiotomy, autoimmune (SLE, RA, sarcoid), uraemic, malignancy, bacterial (TB), radiation. Presentation: pleuritic chest pain (worse on inspiration, better on sitting forward), pericardial friction rub (three-component: atrial systole, ventricular systole, ventricular diastole), diffuse ST elevation + PR depression on ECG. Treatment: NSAIDs (ibuprofen/indomethacin) + colchicine (reduces recurrence). Steroids are second-line for refractory disease or autoimmune causes. Most cases resolve within 1-3 weeks.
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Target exams
Red flags
- Large pericardial effusion developing = risk of tamponade — monitor with serial echo
- Constrictive pericarditis may develop months-years after recurrent pericarditis
- NSAIDs + colchicine is first-line treatment. Steroids are second-line — reserve them
- Differentiate from STEMI: pericarditis has PR depression and diffuse ST elevation (not localised)
Meet the patient
A 34-year-old previously well man arrives with two days of sharp central chest pain that worsens every time he breathes in or lies flat, and eases the moment he sits forward and leans over the bedside table. He had a coryzal illness last week. He is febrile at 37.9 degrees, and the registrar hears a scratchy three-component friction rub at the left sternal edge that comes and goes. The ECG shows diffuse concave ST elevation across most leads with PR depression — and the first instinct of the night-shift cover is to reach for the thrombolysis pathway.[1]
The two questions that decide his next hour are the two that decide every pericarditis stem: is this a STEMI in disguise, or true pericarditis? (the ECG morphology and the clinical story separate them) and is there a treatable cause hiding behind the label "viral"? (TB, purulent, uraemic, autoimmune, malignant each demand a different therapy). Hold those two questions and the whole topic slots into place.[1]
References9ShowHide
- [1]Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review JAMA, 2015.PMID 26461998
- [2]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
- [3]Imazio M, Brucato A, Cemin R, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial Ann Intern Med, 2011.PMID 21873705
- [4]Imazio M, Belli R, Brucato A, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial Lancet, 2014.PMID 24694983
- [5]Brucato A, Imazio M, Gattorno M, et al. Effect of Anakinra on Recurrent Pericarditis Among Patients With Colchicine Resistance and Corticosteroid Dependence: The AIRTRIP Randomized Clinical Trial JAMA, 2016.PMID 27825009
- [6]Klein AL, Imazio M, Cremer P, et al. Phase 3 Trial of Interleukin-1 Trap Rilonacept in Recurrent Pericarditis N Engl J Med, 2021.PMID 33200890
- [7]Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS) Eur Heart J, 2015.PMID 26320112
- [8]Dathe K, Frank J, Padberg S, et al. Fetal adverse effects following NSAID or metamizole exposure in the 2nd and 3rd trimester: an evaluation of the German Embryotox cohort BMC Pregnancy Childbirth, 2022.PMID 36028798
- [9]Klein AL, et al. Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review. JAMA, 2024.PMID 39235771