Pericarditis: Types, Causes, Pathophysiology, Diagnosis, Management and Prevention

Pericarditis

~Introduction

Pericarditis is an inflammatory condition of the pericardium—the thin, double-layered sac that surrounds the heart. It can occur as an isolated disease or as part of a systemic illness. Pericarditis is one of the most common causes of acute chest pain encountered in clinical practice, second only to myocardial infarction. Although most cases are mild and self-limiting, certain forms of pericarditis can lead to serious complications such as cardiac tamponade and constrictive pericarditis, making early recognition essential.

The pericardium consists of a visceral layer (epicardium) adhered to the heart and a parietal layer, between which lies the pericardial space containing 15–50 mL of lubricating fluid. Inflammation of this sac leads to characteristic symptoms, clinical signs, and diagnostic features.

~Anatomy and Physiology of the Pericardium

Structure

• Visceral pericardium: Inner layer directly covering the myocardium.

• Parietal pericardium: Fibrous external layer.

• Pericardial cavity: Small fluid-filled space to reduce friction.

Functions

• Mechanical protection of the heart

• Maintaining optimal cardiac position

• Preventing acute cardiac dilation

• Reducing friction during cardiac movement

• Acting as a barrier to infection

~Types of Pericarditis

Pericarditis is classified based on its duration, underlying pathology, and clinical presentation:

1. Acute Pericarditis – lasting <6 weeks

2. Subacute Pericarditis – 6 weeks to 6 months

3. Chronic Pericarditis – >6 months

4. Recurrent Pericarditis – relapse after initial resolution

Pathological Types

• Fibrinous (Dry) Pericarditis

• Serous Pericarditis

• Purulent (Bacterial) Pericarditis

• Hemorrhagic Pericarditis

• Caseous (Tuberculous) Pericarditis

• Constrictive Pericarditis

~Etiology

Pericarditis has a wide range of causes, though in many Western countries a large proportion is idiopathic (presumed viral).

1. Infectious Causes

Viral

• Coxsackievirus B (most common)

• Echovirus

• Influenza virus

• HIV

• Cytomegalovirus (CMV)

Bacterial

• Staphylococcus

• Streptococcus

• Neisseria meningitidis

• TB (Mycobacterium tuberculosis) → common in developing countries

Fungal

• Histoplasma

• Candida (in immunocompromised patients)

2. Non-Infectious Causes

Autoimmune & Systemic Diseases

• Systemic lupus erythematosus (SLE)

• Rheumatoid arthritis

• Scleroderma

• Post-MI (Dressler’s syndrome)

• Post-pericardiotomy syndrome

Metabolic

• Uremia (chronic kidney disease)

• Hypothyroidism (rare)

Neoplastic

• Lung cancer

• Breast cancer

• Lymphoma

• Leukemia

Trauma

• Penetrating or blunt chest trauma

• Iatrogenic (catheters, pacemaker insertion)

Drugs

• Isoniazid

• Hydralazine

• Procainamide

• Chemotherapy agents (doxorubicin, cyclophosphamide)

~Pathophysiology

Inflammation of the pericardium leads to:

• Edema and infiltration of inflammatory cells

• Increased production of pericardial fluid

• Fibrin deposition (in fibrinous type)

• Formation of adhesions or thickening in chronic forms

Excessive accumulation of fluid can increase pericardial pressure, impairing ventricular filling and leading to cardiac tamponade—a life-threatening emergency.

Repeated inflammation may cause fibrosis and calcification, resulting in constrictive pericarditis, where the heart is encased in a rigid shell limiting diastolic filling.

~Clinical Features

Symptoms

1. Chest Pain (most common)

   • Sharp, stabbing, pleuritic in nature

   • Worse with inspiration, coughing, or lying down

   • Improved by sitting up and leaning forward

   • May mimic myocardial infarction but differs in position and behavior

2. Fever

3. Dyspnea
   – Mainly due to pain or effusion

4. Palpitations
   – If arrhythmias occur

5. Fatigue and malaise

Signs

• Pericardial friction rub: High-pitched, scratchy sound heard best at left lower sternal border; pathognomonic.

• Tachycardia

• Reduced heart sounds (if effusion present)

• Signs of tamponade:

  • Hypotension

  • Jugular venous distension

  • Pulsus paradoxus

  • Weak, muffled heart sounds

~Complications of Pericarditis

1. Pericardial Effusion

Accumulation of fluid in the pericardial space.

2. Cardiac Tamponade

Life-threatening compression of the heart causing obstruction of venous return and reduced cardiac output.

3. Constrictive Pericarditis

Thickened, calcified pericardium restricting heart function.

4. Chronic or Recurrent Pericarditis

Relapses occurring months or years after initial recovery.

~Diagnosis

Diagnosis of pericarditis is made clinically with supportive laboratory and imaging findings.

Diagnostic Criteria

At least two of the following:

1. Characteristic chest pain

2. Pericardial friction rub

3. ECG changes typical of pericarditis

4. Pericardial effusion on imaging

Investigations

1. ECG Findings

Typical stages:

• Stage I: Widespread ST elevation with PR segment depression

• Stage II: ST segments normalize

• Stage III: T-wave inversion

• Stage IV: EKG returns to normal

ECG helps differentiate pericarditis from myocardial infarction.

2. Laboratory Tests

• Elevated ESR, CRP

• Leukocytosis

• Cardiac biomarkers: Mild troponin rise in myopericarditis

• Renal function tests (uremic pericarditis)

• Autoimmune markers (ANA, RF if suspected)

3. Imaging

Echocardiography

• First-line imaging

• Detects pericardial effusion, tamponade physiology

CT Scan

• Shows pericardial thickening, calcification

• Useful for suspected neoplastic pericarditis

MRI

• Excellent for detecting inflammation and fibrosis

• Differentiates constrictive vs. restrictive cardiomyopathy

4. Pericardiocentesis

Indicated in:

• Large effusion

• Cardiac tamponade

• Suspected infection or malignancy

Fluid analysis includes cell count, cultures, cytology, and biochemical markers.

~Management

Management depends on the cause and severity.

1. General Treatment for Acute Pericarditis

A. NSAIDs (First-line)

• Ibuprofen: 600–800 mg every 6–8 hours

• Aspirin (especially post-MI): 650–1000 mg every 6 hours

Given for 1–2 weeks with gradual tapering.

B. Colchicine

Improves symptoms and reduces recurrence.

• Dose: 0.5–1 mg/day for 3 months

C. Corticosteroids

Used only when:

• NSAIDs/colchicine contraindicated

• Autoimmune causes

• Uremic or refractory pericarditis

Risk of recurrence is higher with steroids, so used cautiously.

2. Treatment Based on Specific Causes

Viral Pericarditis

• NSAIDs + Colchicine

• Rest and reassurance

Bacterial Pericarditis

• Intravenous antibiotics

• Pericardial drainage (often required)

Tuberculous Pericarditis

• Anti-TB therapy for 6–12 months

• Steroids may help reduce inflammation

Uremic Pericarditis

• Urgent dialysis

• NSAIDs generally avoided due to kidney dysfunction

Neoplastic Pericarditis

• Treat underlying cancer

• Pericardial window or pericardiectomy if effusion recurs

3. Management of Complications

A. Pericardial Effusion

• Small, asymptomatic: Observe

• Large or symptomatic: Pericardiocentesis

B. Cardiac Tamponade

Medical Emergency

• Immediate pericardiocentesis

• IV fluids to maintain preload

• Avoid positive-pressure ventilation if possible

C. Constrictive Pericarditis

• Diuretics for symptom relief

• Pericardiectomy is the definitive treatment

~Prognosis

The prognosis of pericarditis varies:

Acute idiopathic or viral pericarditis

• Excellent recovery with treatment

• Low mortality

Bacterial or purulent pericarditis

• High mortality if untreated

• Requires aggressive intervention

Tuberculous pericarditis

• Risk of constriction

• Good outcomes with therapy if detected early

Recurrent pericarditis

• Occurs in ~30% of patients

• Colchicine reduces recurrence risk significantly

Constrictive pericarditis

• Requires surgery

• Early intervention leads to good functional recovery

~Prevention

While it is impossible to prevent all forms of pericarditis, certain measures help reduce risk:

• Early treatment of viral infections

• Prompt management of tuberculosis

• Tight control of autoimmune diseases

• Regular dialysis in patients with end-stage renal disease

• Careful use of pericardiotomy and invasive cardiac procedures

• Minimizing unnecessary immunosuppression

~Conclusion

Pericarditis is a clinically significant condition with diverse causes and presentations. Acute pericarditis often presents with sharp chest pain and a characteristic friction rub, and is usually manageable with NSAIDs and colchicine. However, certain forms—especially bacterial, tuberculous, and autoimmune—can be more severe and may lead to life-threatening complications such as cardiac tamponade or chronic constrictive pericarditis.

Appropriate evaluation using ECG, biomarkers, and imaging is crucial for accurate diagnosis. Management depends on the underlying cause and ranges from anti-inflammatory medications to urgent pericardial drainage and even pericardiectomy in advanced cases.

Recognizing pericarditis promptly and initiating timely treatment helps prevent progression, reduce recurrence, and ensure excellent outcomes in most patients.