Diagnosis is Acute pericarditis, most likely idiopathic or presumed viral. If troponin is elevated above the assay upper reference limit with preserved LV systolic function, the diagnosis is myopericarditis.
1. Definition
Acute pericarditis is an inflammatory pericardial syndrome, with or without pericardial effusion, with symptoms lasting ≤4 weeks.
Typical features include:
1. Sharp, pleuritic, positional chest pain
2. Pericardial friction rub
3. Widespread ST-segment elevation and PR-segment depression
4. Evidence of systemic or pericardial inflammation
2. Etiology
Common causes include:
1. Idiopathic or presumed viral
2. Tuberculosis and other bacterial infections
3. Autoimmune or autoinflammatory disease
4. Post-cardiac injury syndromes
5. Malignancy
6. Uremia
7. Drugs and radiation
A preceding viral syndrome supports a presumed viral or post-viral mechanism, but a specific viral cause should not be assumed without evidence.
3. Pathophysiology
Inflammation of the pericardium produces:
1. Pleuritic, positional chest pain
2. Pericardial friction rub
3. Systemic inflammatory marker elevation
4. Pericardial effusion in some patients
A rapidly accumulating significant effusion may cause cardiac tamponade.
Concomitant myocardial involvement may produce troponin elevation and, when more extensive, ventricular dysfunction.
4. Diagnosis
Under the 2025 ESC framework, a definite clinical diagnosis requires a compatible clinical presentation plus more than one additional criterion, including:
1. Pericardial friction rub
2. PR-segment depression or widespread ST-segment elevation
3. Elevated CRP
4. New or worsening pericardial effusion
5. Pericardial edema or late gadolinium enhancement on cardiac MRI
This patient has typical pericardial chest pain, a friction rub, elevated inflammatory markers, and characteristic ECG abnormalities, strongly establishing the diagnosis.
5. Diagnostic Evaluation
5.1 ECG
Typical findings include:
1. Widespread concave ST-segment elevation
2. PR-segment depression
3. Reciprocal PR elevation and ST depression in aVR
4. Absence of a coronary territorial pattern
These findings strongly support pericarditis but do not independently exclude acute coronary syndrome when clinical suspicion for ACS remains.
5.2 Laboratory Findings
1. CRP and ESR are commonly elevated
2. Troponin is generally normal in isolated pericarditis
3. Troponin elevation indicates myocardial injury
Definite pericarditis with elevated troponin but no new LV dysfunction is classified as myopericarditis.
Troponin elevation with new focal or global LV systolic dysfunction suggests predominant myocarditis with pericardial involvement, often termed perimyocarditis.
5.3 Imaging
Transthoracic echocardiography is the first-line imaging test and should assess:
1. Pericardial effusion
2. Cardiac tamponade
3. LV and RV function
A normal echocardiogram does not exclude pericarditis.
Cardiac MRI is particularly useful when the diagnosis is uncertain, myocardial involvement is suspected, or disease is complicated, recurrent, or refractory.
6. Management
6.1 First-Line Therapy
For uncomplicated idiopathic or presumed viral pericarditis:
1. Aspirin or an NSAID at full anti-inflammatory doses
2. Colchicine for 3 months
3. Proton pump inhibitor for gastroprotection
Aspirin or NSAID therapy is generally given for approximately 1 to 2 weeks, then tapered according to symptoms and inflammatory activity.
Colchicine reduces the risk of persistent or recurrent pericarditis.
6.2 Corticosteroids
Corticosteroids are not first-line therapy for uncomplicated idiopathic or presumed viral pericarditis.
Before corticosteroids are introduced because of an incomplete response, the patient should be reassessed for an alternative or specific cause, particularly infection.
Low to moderate dose corticosteroids may be considered when:
1. Aspirin or NSAIDs are contraindicated
2. Symptoms persist despite appropriate first-line treatment after reassessment
3. A specific indication exists, such as autoimmune disease
When required, corticosteroids should generally be used with colchicine and tapered slowly. High doses and rapid tapering increase the risk of recurrence.
6.3 Physical Activity
Restrict strenuous physical activity during active disease.
Return to activity should be individualized and occur after clinical remission, including resolution of symptoms and normalization of inflammatory markers and other abnormal investigations.
For uncomplicated disease, this generally requires at least several weeks, often approximately 1 month.
7. High-Risk Features
Hospital admission and further etiologic evaluation are appropriate when high-risk features are present.
Major high-risk features include:
1. Fever >38°C
2. Subacute onset
3. Large pericardial effusion >20 mm
4. Cardiac tamponade
5. Failure to respond to aspirin or NSAID therapy after at least 1 week
Additional risk features include:
1. Myocardial involvement
2. Immunosuppression
3. Trauma
4. Oral anticoagulant therapy
Patients without high-risk features can often be managed as outpatients with close follow-up.
8. Complications
Important complications include:
1. Recurrent pericarditis
2. Pericardial effusion
3. Cardiac tamponade
4. Myopericarditis
5. Constrictive pericarditis, which is uncommon in idiopathic or presumed viral disease
Key Clinical Insight
Pleuritic positional chest pain relieved by sitting forward + pericardial friction rub + widespread ST-segment elevation and PR-segment depression strongly support acute pericarditis.
First-line treatment is aspirin or an NSAID plus colchicine for 3 months, with gastroprotection.
Troponin elevation indicates myocardial involvement. Pericarditis with elevated troponin and preserved LV function is myopericarditis, while new LV dysfunction suggests predominant myocarditis with pericardial involvement.
References
1. Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46(40):3952-4041. doi:10.1093/eurheartj/ehaf192.
2. Wang TKM, Klein AL, Cremer PC, et al. 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis. J Am Coll Cardiol. 2025;86(25):2691-2719. doi:10.1016/j.jacc.2025.05.023.
3. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528. doi:10.1056/NEJMoa1208536.
4. Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(1):76-92. doi:10.1016/j.jacc.2019.11.021.
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