Pericarditis

Overview

Pericarditis is an inflammation of the pericardium — the thin, two-layered, fluid-filled sac that surrounds and protects the heart. Normally, a small amount of fluid between the two layers allows the heart to move freely with each beat. When the pericardium becomes inflamed, its layers rub against each other, causing pain, and excess fluid may accumulate between them.

Pericarditis is most common in young and middle-aged men, though it can affect people of any age or sex. The majority of cases are caused by a viral infection and resolve completely within a few weeks with appropriate treatment. Bacterial, tuberculous, and autoimmune forms are less common but tend to follow a more severe course and require longer treatment.

The most characteristic feature of pericarditis is chest pain. While it can be easily confused with a heart attack, the pain of pericarditis has a distinctive quality: it typically worsens when lying flat or breathing deeply, and improves when leaning forward. This positional characteristic is an important diagnostic clue.

Pericarditis is generally a benign, self-limiting condition. With appropriate treatment, the vast majority of patients recover fully. However, in some individuals the condition recurs (recurrent pericarditis) or progresses to become chronic, potentially leading to serious complications such as constrictive pericarditis. Accurate diagnosis and close follow-up are therefore important.

Symptoms

Pericarditis symptoms typically begin suddenly and are quite pronounced. In some patients, a few days of fever, malaise, or upper respiratory symptoms may precede the onset of chest pain.

Pericarditis symptoms include the following:

• Sharp, stabbing chest pain. This is the most prominent and most common symptom. The pain is felt in the center or left side of the chest and may radiate to the left shoulder or neck. It worsens noticeably with deep breathing, coughing, or lying flat. It characteristically improves when leaning forward or drawing the knees up to the chest — a hallmark feature that helps distinguish pericarditis from other causes of chest pain.
• Fever and chills. A low-to-moderate fever (37.5–39°C) is common, particularly in viral cases. Chills, sweating, and a general sense of illness may accompany it.
• Fatigue and malaise. Marked weakness and a significant drop in energy levels are frequently reported. Daily activities may become difficult to sustain.
• Shortness of breath. Because deep breathing is painful, patients tend to breathe shallowly, which can create a sensation of breathlessness. If pericardial fluid accumulates significantly (pericardial effusion), it may compress the heart and cause more serious shortness of breath.
• Palpitations. Cardiac arrhythmias — particularly atrial fibrillation — may develop during pericarditis. Palpitations are felt as a rapid, irregular, or pounding heartbeat.
• Cough. A dry cough can develop, particularly as fluid accumulates and irritates surrounding tissues.
• Difficulty swallowing. Rarely, a large pericardial effusion may compress the esophagus and make swallowing uncomfortable.

Pericarditis pain can be confused with that of a heart attack. However, cardiac chest pain is typically described as a crushing pressure that does not change with position; pericarditis pain is sharp, positional, and breathing-related. While this distinction is a useful guide, medical evaluation is always required to rule out life-threatening causes.

When to See a Doctor

Chest pain should always be taken seriously. Even when pericarditis is suspected, life-threatening conditions such as a heart attack must first be excluded.

Schedule a prompt medical evaluation if:

• You have new-onset chest pain — regardless of its suspected cause
• You have fever accompanied by chest pain
• You have shortness of breath and chest pain occurring together
• You have previously been diagnosed with pericarditis and symptoms have returned
• You have an autoimmune condition and develop chest pain
• Chest pain begins shortly after recovering from a viral infection

Call emergency services immediately if you experience:

• Severe, crushing chest pain — especially if it radiates to the arm, jaw, or back
• Sudden inability to breathe, cold sweating, or dizziness alongside chest pain
• Fainting or loss of consciousness
• Rapid, irregular heartbeat accompanied by chest pain

Causes

Pericarditis can result from many different underlying causes. In a substantial proportion of cases, no definitive cause is identified — these cases are classified as idiopathic pericarditis.

Possible causes of pericarditis include the following:

• Viral infections. This is the most common cause. Coxsackievirus, echovirus, influenza, Epstein-Barr virus, cytomegalovirus, and HIV are among the leading agents. COVID-19 infection and, less commonly, COVID-19 vaccination have also been associated with pericarditis. Viral pericarditis typically resolves on its own.
• Idiopathic pericarditis. In 80–90 percent of cases, no specific cause can be identified. The underlying trigger is most likely viral but cannot be confirmed through laboratory testing. This group carries a generally favorable prognosis.
• Bacterial infections. Streptococci, staphylococci, and pneumococci can cause purulent (suppurative) pericarditis. This form follows a more severe course and may require antibiotic therapy and drainage.
• Tuberculosis. Mycobacterium tuberculosis settling in the pericardium causes tuberculous pericarditis. It is an important cause in developing countries, follows a slow and insidious course, and can lead to constrictive pericarditis if diagnosed late.
• Autoimmune and inflammatory diseases. Systemic lupus erythematosus (SLE), rheumatoid arthritis, systemic sclerosis, and Sjögren's syndrome can all involve the pericardium. In these conditions, pericarditis tends to recur as part of the underlying disease course.
• Post-myocardial infarction pericarditis (Dressler syndrome). An autoimmune pericarditis — known as Dressler syndrome — can develop days to weeks after a heart attack. It results from an immune response directed against damaged cardiac tissue that secondarily inflames the pericardium.
• Cardiac surgery and procedures. Open heart surgery and catheter-based procedures such as ablation can trigger post-pericardiotomy syndrome — fever and pericarditis symptoms appearing days to weeks after the procedure.
• Radiation therapy. Radiation delivered to the chest — particularly for lymphoma, breast cancer, or lung cancer — can damage the pericardium, causing pericarditis and, in the longer term, predisposing to constrictive pericarditis.
• Kidney failure. In advanced chronic kidney disease, accumulating uremic toxins irritate the pericardium, causing uremic pericarditis. It typically improves with intensification of dialysis therapy.
• Medications. Hydralazine, procainamide, isoniazid, and some chemotherapeutic agents rarely cause drug-induced pericarditis. In medication-related cases, the condition usually resolves after the offending drug is discontinued.

Risk Factors

Several factors are associated with an increased risk of developing pericarditis:

• Male sex and young-to-middle age. Pericarditis most commonly affects men between the ages of 20 and 50. It is less common in women, though autoimmune pericarditis is proportionally more frequent in women.
• Recent viral infection. A history of upper respiratory tract infection or influenza in the 1–3 weeks preceding symptoms is an important risk factor.
• Autoimmune diseases. SLE, rheumatoid arthritis, and other inflammatory conditions increase both the risk of pericarditis and the likelihood of recurrence.
• Prior episode of pericarditis. Individuals who have had pericarditis once face a 15–30 percent risk of recurrence. Each recurrence raises the risk of further episodes.
• Cardiac surgery or chest trauma. Open heart surgery, catheter procedures, and chest injuries increase the risk of pericarditis.
• Chest radiation therapy. Patients who have received thoracic radiation for breast cancer, lymphoma, or lung cancer face an elevated risk.
• Tuberculosis exposure. Living in or traveling to regions where tuberculosis is endemic, or having contact with someone with active tuberculosis, increases risk.
• Immunosuppression. HIV infection, post-transplant immunosuppressive therapy, and long-term corticosteroid use may increase susceptibility to pericarditis.

Diagnosis

Pericarditis is diagnosed through a combination of clinical assessment, electrocardiography, and imaging. Diagnosis is generally established when at least two of four classic criteria are met: typical chest pain, pericardial friction rub, characteristic ECG changes, and new pericardial effusion.

Diagnostic methods include the following:

• Medical history and physical examination. The character of the pain, its relationship to position and breathing, and accompanying symptoms are carefully assessed. On auscultation, a pericardial friction rub — a scratching or grating sound produced by the inflamed pericardial layers rubbing together — strongly supports the diagnosis. This sound is not always present, however.
• Electrocardiography (ECG). Pericarditis produces characteristic ECG changes. In the early phase, widespread ST-segment elevation and PR-segment depression are seen across multiple leads. This pattern of changes differs from that of a heart attack and can be distinguished by an experienced clinician.
• Blood tests. Inflammatory markers — C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) — are elevated during active pericarditis. Troponin elevation indicates coexisting myocarditis (inflammation of the heart muscle). A complete blood count, renal function tests, thyroid hormones, and autoimmune markers are ordered to investigate the underlying cause.
• Echocardiography. This is used to visualize pericardial fluid, assess its volume, evaluate cardiac function, and exclude dangerous complications such as cardiac tamponade. Echocardiography is recommended in all confirmed cases of pericarditis.
• Chest X-ray. When pericardial effusion exceeds a certain volume, the cardiac silhouette appears enlarged. Chest X-ray also helps exclude pulmonary disease and other thoracic pathology.
• Cardiac MRI. This provides the most detailed imaging of the pericardium, demonstrating inflammation, thickening, and the presence of myocarditis. It is particularly useful in diagnostically challenging cases and in recurrent pericarditis.
• CT scan. Useful for evaluating pericardial calcification and thickening, particularly when constrictive pericarditis is suspected.

Treatment

The primary goals of pericarditis treatment are to suppress inflammation, relieve pain, prevent complications, and reduce the risk of recurrence. The treatment approach is guided by disease severity and the underlying cause.

Treatment options include the following:

• Rest and activity restriction. Physical rest is an important part of treatment. Strenuous physical activity should be avoided until symptoms resolve and inflammatory markers return to normal. In athletes, return to competitive sport typically requires waiting at least three months and confirming normalization of ECG and echocardiography findings.
• Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). These are the first-line treatment. Ibuprofen or aspirin — with their combined analgesic and anti-inflammatory effects — form the backbone of pericarditis therapy. The dose is tapered gradually; abrupt discontinuation increases the risk of relapse. A gastroprotective agent (proton pump inhibitor) is recommended alongside.
• Colchicine. Added to NSAID therapy, colchicine both accelerates recovery and substantially reduces the risk of recurrence. It has become a standard component of pericarditis treatment. It is typically prescribed for 3–6 months. Gastrointestinal side effects (nausea, diarrhea) may occur.
• Corticosteroids. Reserved for cases that do not respond to NSAIDs and colchicine, as well as autoimmune or uremic etiologies. Corticosteroids must be used cautiously and at the lowest effective dose, as evidence suggests they may paradoxically increase recurrence risk. They are never a first-line choice.
• Anakinra and other biologic agents. For refractory recurrent pericarditis unresponsive to standard therapy including colchicine, the IL-1 blocker anakinra has emerged as an effective option. It is administered in specialized centers.
• Treatment of the underlying cause. Bacterial pericarditis requires antibiotics; tuberculous pericarditis requires four-drug antitubercular therapy; autoimmune pericarditis is managed with treatment directed at the underlying disease; uremic pericarditis may require intensification of dialysis.
• Pericardiocentesis. If pericardial fluid accumulates to the point of causing cardiac tamponade, or if diagnostic fluid sampling is needed, the fluid is drained using a needle guided by echocardiography.
• Pericardiectomy. Surgical removal of the pericardium may be necessary in recurrent cases or when constrictive pericarditis develops. This is considered a last resort.

Complications

With appropriate treatment, pericarditis resolves without complications in the majority of cases. However, a subset of patients develop serious complications:

• Pericardial effusion. Inflammation can cause excess fluid to accumulate between the pericardial layers. Small effusions are often asymptomatic and resolve on their own. However, rapidly accumulating or large effusions can compress the heart and lead to tamponade.
• Cardiac tamponade. Rapid accumulation of a large volume of pericardial fluid compresses the heart, preventing it from filling and pumping adequately. Blood pressure falls, the heart rate rises, and breathlessness worsens. This life-threatening emergency requires immediate pericardiocentesis.
• Recurrent pericarditis. Approximately 15–30 percent of patients experience at least one recurrence after the initial episode. Each recurrence restarts the symptom burden and treatment process. Colchicine significantly reduces recurrence risk.
• Constrictive pericarditis. Chronic or recurrent inflammation can cause the pericardium to thicken, stiffen, and form a rigid shell around the heart, impairing its filling. This complication is relatively uncommon (occurring in approximately 1–2 percent of cases) but is serious and often requires surgical pericardiectomy.
• Myocarditis. In some cases, inflammation extends to involve the heart muscle — a condition called myopericarditis. Elevated troponin levels indicate myocardial involvement. Most cases resolve spontaneously, but close monitoring is required.

Living with Pericarditis

Most people diagnosed with pericarditis recover fully within a few weeks with appropriate treatment and return to their normal lives. There are, however, important considerations during and after recovery.

Physical Activity and Rest

Restricting physical activity during recovery both accelerates healing and reduces the risk of complications. Avoid heavy exercise, competitive sport, and physically demanding work until symptoms have fully resolved and inflammatory markers have normalized. If you are an athlete, obtain explicit clearance from your doctor before returning to training — this typically takes a minimum of three months. Light walking and routine daily activities can generally be maintained as tolerated.

Medication Adherence

Do not reduce your medication dose or stop treatment abruptly without your doctor's guidance — doing so significantly increases the risk of relapse. Follow the tapering schedule your doctor prescribes carefully. Take colchicine for the full prescribed duration; stopping early substantially raises the recurrence risk. Report any gastrointestinal side effects promptly, as a gastroprotective agent can be added.

Monitor Your Symptoms

Track the evolution of fever, chest pain, and shortness of breath throughout treatment. Contact your doctor without delay if symptoms worsen or new symptoms develop. A sudden worsening of breathlessness warrants urgent evaluation for cardiac tamponade.

Alcohol and Smoking

Avoid alcohol during the recovery period — it can interfere with inflammatory markers and may interact with certain medications. Quitting smoking supports both pericardial health and overall cardiovascular well-being.

Regular Follow-up

Continue attending follow-up appointments after treatment ends. Inflammatory markers and echocardiography should confirm complete resolution. If you have a history of recurrent pericarditis, more frequent and prolonged monitoring will be planned. Remember that seeking medical attention early when new symptoms arise improves outcomes.

Preparing for Your Appointment

Coming prepared to your appointment helps your doctor reach an accurate diagnosis and select the most appropriate treatment without delay.

What you can do:

• Note when the chest pain began, what it feels like, and how its intensity changes with position and breathing
• Mention any viral infection, flu, or cold you have had in the past few weeks
• List all current medications, vitamins, and supplements
• Inform your doctor of any prior diagnosis of pericarditis, heart disease, or autoimmune condition
• Report any recent cardiac surgery, catheter procedure, or chest trauma
• Mention any family history of heart or autoimmune disease
• Write down your questions in advance

Questions you may wish to ask your doctor:

• Is the pericarditis diagnosis confirmed, or are other conditions still being considered?
• What treatment do you recommend, and how long will it last?
• When can I return to exercise or strenuous physical activity?
• Could the condition recur, and what can I do to prevent it?
• Which symptoms should prompt me to seek urgent care?
• Do I have pericardial fluid, and is it dangerous?
• Is there an underlying cause that needs to be investigated?
• How often should I come for follow-up?

Questions your doctor may ask:

• When did the chest pain start, and how would you describe it?
• Does leaning forward ease the pain? Does deep breathing make it worse?
• Have you had a viral infection recently?
• Have you had a fever?
• Are you experiencing shortness of breath or palpitations?
• Have you had pericarditis before?
• Do you have known heart disease or an autoimmune condition?
• Have you recently had cardiac surgery or an interventional procedure?
• What medications are you currently taking?