Pericarditis & Pericardial Disease
Inflammation of the pericardium. Usually viral and self-limited. The danger: missing tamponade and confusing it with STEMI. Colchicine reduces recurrence by 50%.
🔍 Overview
Diagnosis (≥ 2 of 4 criteria)
- Pleuritic chest pain -sharp, worse with inspiration and supine, improved leaning forward
- Pericardial friction rub -scratchy, 3-component (best heard with diaphragm, patient leaning forward)
- Diffuse ST elevation with PR depression (concave-up, diffuse -NOT territorial like STEMI)
- New or worsening pericardial effusion on echo
Pericarditis vs STEMI on ECG
| Feature | Pericarditis | STEMI |
|---|---|---|
| ST elevation | Diffuse, concave-up ("smiley face") | Territorial (matches coronary distribution), convex-up |
| PR segment | PR depression (except aVR -PR elevation) | Usually normal |
| Reciprocal changes | None (except aVR) | Present (ST depression in opposite leads) |
| Q waves | Absent | May develop |
| T-wave evolution | ST normalizes BEFORE T inversions | T inversions occur WITH persistent ST elevation |
Cardiac Tamponade
Tamponade is a clinical diagnosis, not an echocardiographic one. A large effusion can be well-tolerated (chronic); a small rapidly accumulating effusion can cause tamponade.
- Beck's triad: hypotension, JVD, muffled heart sounds (only ~30% have all three)
- Pulsus paradoxus > 10 mmHg (SBP drop > 10 with inspiration) -most sensitive clinical sign
- Echo: RA collapse in systole (earliest), RV diastolic collapse, IVC plethora (no collapse with inspiration)
- Electrical alternans on ECG (swinging heart) -classic but uncommon
- Treatment: emergent pericardiocentesis -subxiphoid approach, echo-guided. Drain as much as possible. Send fluid for cell count, protein, LDH, glucose, gram stain, culture, cytology, ADA.
🚨 Management
Acute Pericarditis -Treatment
| Drug | Dose | Duration | Notes |
|---|---|---|---|
| NSAIDs 1ST LINE | Ibuprofen 600 mg PO TID or ASA 750–1000 mg PO TID | 1–2 weeks, taper over 2–4 weeks | First-line anti-inflammatory. ASA preferred post-MI (NSAIDs impair scar formation). Add PPI for gastric protection. |
| Colchicine (Colcrys) ADD TO ALL | 0.5 mg BID (if > 70 kg) or 0.5 mg daily (if ≤ 70 kg) | 3 months | COPE, 2005 + ICAP, 2013: colchicine reduced recurrence by ~50%. Should be added to ALL pericarditis treatment. GI side effects (diarrhea). Renal dose if CrCl < 30. |
| Corticosteroids LAST RESORT | Prednisone 0.25–0.5 mg/kg/day | Taper over weeks–months | Avoid if possible -steroids increase recurrence rate. Use only if NSAIDs + colchicine contraindicated or failed, or autoimmune etiology confirmed. Taper VERY slowly. |
Exercise restriction: Non-athletes → restrict until symptoms resolve + CRP normalizes. Athletes → minimum 3 months of no competitive sports ESC 2015 guidelines.
📋 On Rounds
Pimp Questions
Why do steroids increase recurrence in pericarditis?
Steroids suppress the immune response so effectively that the underlying viral/inflammatory process doesn't fully resolve -it smolders. When you taper the steroids, the inflammation rebounds. This is why COPE, 2005 and subsequent studies showed steroids as an independent predictor of recurrence. Colchicine, by contrast, modulates the inflammatory response without suppressing it entirely, leading to more durable resolution.
How do you differentiate pericardial effusion from tamponade?
Effusion is an anatomic finding. Tamponade is a hemodynamic diagnosis. A patient can have a massive chronic effusion with no hemodynamic compromise (the pericardium stretches slowly). Conversely, 200 mL accumulating rapidly (e.g., post-procedure, trauma, aortic dissection) can cause tamponade. The diagnosis is clinical: hypotension + JVD + pulsus paradoxus + echo showing diastolic chamber collapse.
When should you suspect cardiac tamponade in a patient with pericarditis?
Beck's triad: hypotension + JVD + muffled heart sounds (only 10-40% have all three). More reliable: pulsus paradoxus > 10 mmHg (SBP drops > 10 during inspiration). Best bedside test: echo showing diastolic RV collapse (most specific), RA collapse, IVC plethora (dilated, no respiratory variation), respiratory variation in mitral/tricuspid inflow velocities.
Why do you add colchicine to NSAIDs for pericarditis?
COPE, 2005 and ICAP, 2011: adding colchicine to NSAIDs halved the recurrence rate from ~30% to ~15%. Colchicine inhibits tubulin polymerization → blocks neutrophil chemotaxis and inflammasome activation. Dose: 0.5 mg BID (or 0.5 mg daily if < 70 kg) × 3 months for first episode, × 6 months for recurrence. Start colchicine on day 1 -not just for recurrence prevention.
Clinical Examples
📋 Case 1, Acute Viral Pericarditis with Myopericarditis
Patient: 26M, previously healthy, presents with 2 days of sharp pleuritic chest pain worse lying flat and improved leaning forward. Recent URI 10 days ago.
Key findings: T 100.4°F, HR 88, BP 122/74. Pericardial friction rub on auscultation. ECG: diffuse concave ST elevation + PR depression. Troponin 0.18 (mildly elevated). CRP 8.4. Echo: small circumferential effusion, no tamponade.
Management:
- Ibuprofen 600 mg PO TID x 1-2 weeks, then taper by 200-400 mg/week. PPI for GI protection.
- Colchicine 0.5 mg BID x 3 months (reduces recurrence by ~50%)
- Activity restriction until symptoms resolved AND CRP normalized (critical with troponin elevation)
- Repeat echo in 1 week; CRP weekly until normalized
- Avoid steroids, increase recurrence risk
Teaching point: The mildly elevated troponin indicates myopericarditis (myocardial involvement). This does not change treatment but mandates strict exercise restriction, return to sport only after 3-6 months symptom-free with normal CRP, ECG, and echo. ICAP, 2013
📋 Case 2, Recurrent Pericarditis on Steroid Taper
Patient: 41F, 3rd episode of pericarditis in 18 months. Initially treated with NSAIDs alone (no colchicine). Second episode treated with prednisone 40 mg with rapid taper. Now recurs 2 weeks after completing steroid taper.
Key findings: Pleuritic chest pain, CRP 12.8, small effusion on echo. No tamponade physiology. ECG with recurrent ST changes.
Management:
- Restart ibuprofen 600 mg TID + colchicine 0.5 mg BID x 6 months (longer duration for recurrence)
- If steroid-dependent: very slow taper (decrease by 2.5 mg every 2-4 weeks only if asymptomatic + CRP normal)
- If refractory to colchicine + NSAIDs + slow steroid taper: consider anakinra (IL-1 receptor antagonist)
- Avoid exercise until CRP normalizes
Teaching point: Steroids are an independent risk factor for recurrent pericarditis. COPE, 2005 demonstrated colchicine should be first-line for all pericarditis. In steroid-dependent recurrent pericarditis, AIRTRIP, 2016 showed anakinra achieved complete response in 80%+ of patients.
📋 Case 3, Post-MI Pericarditis (Dressler Syndrome)
Patient: 63M, admitted 3 weeks ago for anterior STEMI with PCI to LAD. Now re-presents with pleuritic chest pain, low-grade fever, and new pericardial friction rub.
Key findings: ECG: diffuse ST elevation (different from prior focal anterior changes). Troponin re-elevated to 0.42. CRP 15.2. Echo: moderate pericardial effusion, no tamponade. On aspirin 81 mg + ticagrelor (DAPT).
Management:
- Aspirin 750-1000 mg TID (preferred NSAID post-MI)
- Colchicine 0.5 mg BID x 3 months
- Avoid ibuprofen post-MI, interferes with aspirin's antiplatelet effect
- Continue DAPT (do not stop ticagrelor for pericarditis)
- Monitor for tamponade, anticoagulated patients at higher risk of hemorrhagic effusion
Teaching point: Dressler syndrome is autoimmune pericarditis occurring 2-10 weeks post-MI. Use aspirin (not ibuprofen) as the anti-inflammatory because ibuprofen competitively inhibits aspirin's irreversible COX-1 platelet binding. Avoid anticoagulation if large effusion due to hemorrhagic tamponade risk.
📣 Sample Presentation
One-Liner
"Mr. Okafor is a 24-year-old presenting with sharp pleuritic chest pain worse lying flat, improved leaning forward, following a URI 10 days ago. ECG shows diffuse ST elevation with PR depression. Troponin mildly elevated at 0.15 suggesting myopericarditis."
Key Points to Cover on Rounds
Etiology: likely viral (post-URI). Troponin 0.15 (mild, myopericarditis). Echo: small pericardial effusion, no tamponade physiology. CRP 8.4 (elevated, will trend). Treatment: ibuprofen 600 mg TID × 2 weeks + colchicine 0.5 mg BID × 3 months. Pain improving. Avoiding exercise until CRP normalizes and symptoms resolve. Plan: repeat echo in 1 week, CRP weekly.
Monitoring -Pericarditis & Pericardial Disease
| Parameter | Frequency | Target / Action |
|---|---|---|
| CRP | Weekly until normal | Guides duration of therapy. Do NOT taper NSAIDs until CRP normalizes. Premature taper = recurrence. |
| ECG | At diagnosis, then at follow-up | Monitor ST/PR normalization through 4 stages. Persistent changes may suggest constrictive physiology. |
| TTE (Echo) | Repeat in 1-2 weeks | Confirm effusion resolution. Repeat sooner if hemodynamic compromise or clinical worsening. |
| Symptoms | Each visit | Pleuritic chest pain, dyspnea, positional symptoms. Worsening = consider effusion enlargement or recurrence. |
| Renal function (Cr) | 1-2 weeks after starting NSAIDs | NSAID nephrotoxicity. Check BMP especially in elderly, CKD, heart failure, or concurrent ACEi/ARB. |
| Activity restriction | Until CRP normal + asymptomatic | Non-athletes: restrict until symptom resolution. Athletes: no competitive sports for minimum 3 months (6 months if myopericarditis). |
🧪 Workup
Workup -Pericarditis & Pericardial Disease
| Test | Findings | Clinical Significance |
|---|---|---|
| 12-lead ECG | Diffuse ST elevation (concave up), PR depression, Spodick sign (downsloping TP segment) | Stage I changes present in ~80%. Diffuse = not in a coronary territory (distinguishes from STEMI). |
| TTE (Echocardiogram) | Pericardial effusion size, tamponade physiology (RA/RV collapse, IVC plethora, respiratory variation) | Assess effusion size and hemodynamic impact. Repeat in 1-2 weeks to monitor resolution. |
| Troponin | Elevated if myopericarditis | Mild elevation suggests myocardial involvement. Does NOT change treatment but restricts activity longer. |
| CRP / ESR | Elevated (CRP often markedly) | CRP guides treatment duration -continue colchicine + NSAIDs until CRP normalizes. |
| CBC | Leukocytosis (if infectious/inflammatory) | WBC differential helps distinguish viral (lymphocytic) vs bacterial (neutrophilic). |
| BMP | Cr (baseline), electrolytes | Baseline renal function before NSAID therapy. Monitor during treatment. |
| Blood cultures | If infectious etiology suspected | Obtain if febrile, immunocompromised, or subacute presentation suggesting bacterial/TB pericarditis. |
Diagnosis requires 2 of 4: (1) pleuritic chest pain, (2) pericardial friction rub, (3) diffuse ST elevation + PR depression, (4) new/worsening pericardial effusion.
💊 Medications
Medications -Pericarditis & Pericardial Disease
| Drug | Dose | Duration | Notes |
|---|---|---|---|
| Ibuprofen (Advil) 1ST LINE | 600 mg PO TID | 1-2 weeks, then taper over 2-3 weeks | First-line NSAID. Take with PPI for GI protection. Taper by 200-400 mg/week. |
| Colchicine (Colcrys) 1ST LINE | 0.5 mg BID (0.5 mg daily if <70 kg) | 3 months (first episode), 6 months (recurrent) | Halves recurrence rate. COPE, 2005 + ICAP, 2013. GI side effects (diarrhea) -dose-reduce if needed. |
| Aspirin | 750-1000 mg PO TID | 1-2 weeks, then taper | Preferred over ibuprofen if recent MI (post-infarction pericarditis / Dressler syndrome). |
| Prednisone 2ND LINE ONLY | 0.25-0.5 mg/kg/day | Slow taper over weeks-months | Only if contraindication to NSAIDs (renal failure, GI bleeding). Increases recurrence risk. Always use with colchicine. |
Avoid anticoagulants if moderate-large effusion -risk of hemorrhagic pericardial effusion and tamponade. If on anticoagulation for other indication, discuss risk-benefit with cardiology.
⚡ Summary
Summary
Diagnose on Two of Four
Pleuritic chest pain, a pericardial friction rub, diffuse ST elevation with PR depression, and a new or worsening pericardial effusion. Any two make the diagnosis. The pain is classically sharp, worse lying flat and relieved by sitting forward, which is a useful discriminator from ischemic pain.
Separate It From STEMI on the ECG
Pericarditis: diffuse ST elevation across multiple territories, concave upward, with PR depression and no reciprocal change (except in aVR, where the ST depresses and the PR elevates). STEMI: territorial ST elevation, often convex, with reciprocal depression. Getting this wrong sends a pericarditis patient to the cath lab or, far worse, sends a STEMI patient home on ibuprofen.
Colchicine Is Not Optional
Add colchicine to the NSAID for 3 months: it roughly halves recurrence (ICAP, CORP). It is the single highest-yield element of the regimen and it is frequently omitted. Dose-reduce for renal impairment and for weight below 70 kg, and warn about diarrhea.
NSAIDs at Anti-Inflammatory Doses, Then Taper
High-dose ibuprofen or aspirin until symptoms resolve and CRP normalizes, then taper rather than stopping abruptly, which precipitates rebound. Use aspirin, not other NSAIDs, in post-MI pericarditis, because other NSAIDs impair infarct healing and increase the risk of wall rupture.
Avoid Steroids as First Line
Corticosteroids relieve symptoms quickly but substantially increase recurrence, creating a steroid-dependent course that is much harder to treat. Reserve them for specific indications: connective tissue disease, uremic pericarditis, or genuine NSAID and colchicine failure or contraindication.
Tamponade Is a Clinical Diagnosis
Not an echocardiographic one. A large chronic effusion can be entirely well tolerated, while a small, rapidly accumulating one causes tamponade, because the pericardium has not had time to stretch. Look for hypotension, raised JVP, muffled sounds, tachycardia and pulsus paradoxus, and treat with drainage, not diuretics.
Track CRP, and Restrict Exercise
CRP guides both the taper and the confirmation of resolution. Non-athletes: restrict until symptoms resolve and CRP normalizes. Athletes: a minimum of 3 months away from competitive sport (ESC), because exertion during active inflammation increases recurrence and arrhythmic risk.
Look for a Cause in the Minority Who Need It
Most acute pericarditis is viral or idiopathic and needs no workup beyond ECG, troponin, CRP, chest x-ray and echocardiography. Investigate further for high-risk features: fever above 38°C, subacute onset, a large effusion or tamponade, failure to respond after a week, immunosuppression, trauma or anticoagulation. Then consider tuberculosis, malignancy, uremia, autoimmune disease and bacterial pericarditis, and remember myopericarditis, where a raised troponin means myocardial involvement and warrants closer follow-up of ventricular function.
📄 One Pager
Text version
Cardiology · One Pager
Acute Pericarditis
Pleuritic chest pain + diffuse ST elevation + PR depression. NSAIDs + colchicine. Always rule out tamponade. Avoid anticoagulation.
Diagnosis -Need 2 of 4
- Pleuritic chest pain (sharp, worse lying flat, better leaning forward)
- Pericardial friction rub
- Diffuse ST elevation + PR depression on ECG
- New or worsening pericardial effusion on echo
Management
- Ibuprofen 600 mg TID × 2 weeks (taper over weeks)
- Colchicine 0.5 mg BID × 3 months (halves recurrence) [COPE, 2005, ICAP, 2013]
- Activity restriction until CRP normalizes + symptoms resolve
- Myopericarditis (troponin ↑): no exercise × 3-6 months
Tamponade -Recognize Early
- Beck's triad: hypotension + JVD + muffled heart sounds
- Pulsus paradoxus > 10 mmHg
- Echo: RV diastolic collapse (most specific), IVC plethora
- Treatment: emergent pericardiocentesis (echo-guided)
Key Drugs
Ibuprofen600 mg TID × 2wk
Colchicine0.5 mg BID × 3mo
AcetaminophenPRN adjunct
AvoidAnticoagulation, steroids first-line
Pitfalls
- Missing tamponade
- Using steroids first-line (high recurrence)
- Anticoagulation → hemorrhagic effusion
- Not adding colchicine from day 1
- Confusing with STEMI on ECG
Related Topics
ACS OverviewAortic DissectionAortic StenosisArrhythmiasAtrial FibrillationCardiac Tamponade