Advertisement
Previous article
Substance Misuse in Adults: A Primary Care Approach
May 2024
Next article
Falls in Older Adults: Approach and Prevention

Acute Pericarditis: Rapid Evidence Review

Thomas A. Peterson, MD
Sean P. Turner, MD
Katelyn A. Dolezal, MD

American Family Physician. 2024;109(5):441-446.

Author disclosure: No relevant financial relationships.

Acute pericarditis is defined as inflammation of the pericardium and occurs in approximately 4.4% of patients who present to the emergency department for nonischemic chest pain, with a higher prevalence in men. Although there are numerous etiologies of pericarditis, most episodes are idiopathic and the cause is presumed to be viral. Diagnosis of pericarditis requires at least two of the following criteria: new or worsening pericardial effusion, characteristic pleuritic chest pain, pericardial friction rub, or electrocardiographic changes, including new, widespread ST elevations or PR depressions. Pericardial friction rubs are highly specific but transient, and they have been reported in 18% to 84% of patients with acute pericarditis. Classic electrocardiographic findings include PR-segment depressions; diffuse, concave, upward ST-segment elevations without reciprocal changes; and T-wave inversions. Transthoracic echocardiography should be performed in all patients with acute pericarditis to characterize the size of effusions and evaluate for complications. Nonsteroidal anti-inflammatory drugs are the first-line treatment option. Glucocorticoids should be reserved for patients with contraindications to first-line therapy and those who are pregnant beyond 20 weeks' gestation or have other systemic inflammatory conditions. Colchicine should be used in combination with first- or second-line treatments to reduce the risk of recurrence. Patients with a higher risk of complications should be admitted to the hospital for further workup and treatment.

Acute pericarditis, or inflammation of the pericardium, has numerous etiologies and often produces a characteristic pleuritic chest pain. This article reviews patient-oriented evidence to guide the diagnosis and management of acute pericarditis.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Evaluation of acute pericarditis should include a patient history, physical examination, electrocardiography, chest radiography, transthoracic echocardiography, and baseline laboratory studies.6 C Expert consensus guidelines
All patients with acute pericarditis should be treated with colchicine (Colcrys) and nonsteroidal anti-inflammatory drugs or glucocorticoids to reduce the risk of recurrence.35–38 A Systematic reviews and meta-analyses with patient-oriented outcomes
Patients with acute pericarditis who have risk factors for serious disease or complications should be hospitalized for further treatment and etiologic workup.6,20 B Two prospective cohort studies
Athletes with acute pericarditis should not participate in competitive sports for 3 months after being diagnosed or for 3 to 6 months in those with myopericarditis.6,45 C Expert consensus guidelines

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

  • In one small study, acute pericarditis was diagnosed in 4.4% of patients admitted to the emergency department with nonischemic chest pain; it accounts for 0.2% of cardiovascular hospital admissions.1,2 The exact incidence of acute pericarditis is difficult to estimate because epidemiologic studies are lacking, and mild cases likely resolve without being formally diagnosed.3,4
  • Acute pericarditis occurs mostly in adult patients, with a mean age in the 50s.3–9 Hospital registry data suggest that men are more likely to be affected by acute pericarditis than women, with incidence ratios of 1.7 to 2.0 in men to 1.0 in women.2–5
  • Acute pericarditis is typically a result of systemic disease or related to processes involving the pericardium3,6,9–15 (eTable A).
  • Despite advances in diagnostic testing, more than 50% of episodes are idiopathic and the etiology is presumed to be viral.3,5 Pericarditis after cardiac injury is emerging as the second leading cause of pericarditis and occurs in 9% to 33% of patients.3,5,6,9–14
  • Tuberculosis accounts for up to 70% of pericarditis in endemic areas but is a rare etiology in nonendemic areas.9–14,16

THOMAS A. PETERSON, MD, is residency faculty at the Madigan Army Medical Center Family Medicine Residency Program, Tacoma, Wash.; an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.; and a clinical instructor in the Department of Family Medicine at the University of Washington School of Medicine, Seattle.

SEAN P. TURNER, MD, is residency faculty at the Madigan Army Medical Center Family Medicine Residency Program, an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, and a clinical instructor in the Department of Family Medicine at the University of Washington School of Medicine.

KATELYN A. DOLEZAL, MD, is associate program director of the Madigan Army Medical Center Family Medicine Residency Program and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Thomas A. Peterson, MD, Madigan Army Medical Center, 9040 Jackson Ave., Joint Base Lewis-McChord, WA 98431 (thomas.a.peterson86.mil@health.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.Fruergaard P, Launbjerg J, Hesse B, et al. The diagnoses of patients admitted with acute chest pain but without myocardial infarction. Eur Heart J. 1996;17(7):1028-1034.
  2. 2.Kytö V, Sipilä J, Rautava P. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation. 2014;130(18):1601-1606.
  3. 3.Gouriet F, Levy PY, Casalta JP, et al. Etiology of pericarditis in a prospective cohort of 1162 cases. Am J Med. 2015;128(7):784.e1-784.e8.
  4. 4.Kumar N, Pandey A, Jain P, et al. Acute pericarditis-associated hospitalization in the USA: a nationwide analysis, 2003–2012. Cardiology. 2016;135(1):27-35.
  5. 5.Vecchié A, Chiabrando JG, Dell MS, et al. Clinical presentation and outcomes of acute pericarditis in a large urban hospital in the United States of America. Chest. 2020;158(6):2556-2567.
  6. 6.Adler Y, Charron P, Imazio M, et al.; ESC Scientific Document Group. 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;36(42):2921-2964.
  7. 7.Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042-1046.
  8. 8.Imazio M, Cecchi E, Demichelis B, et al. Myopericarditis versus viral or idiopathic acute pericarditis. Heart. 2008;94(4):498-501.
  9. 9.Shakti D, Hehn R, Gauvreau K, et al. Idiopathic pericarditis and pericardial effusion in children: contemporary epidemiology and management. J Am Heart Assoc. 2014;3(6):e001483.
  10. 10.Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management. Am Fam Physician. 2014;89(7):553-560.
  11. 11.Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75(5):378-382.
  12. 12.Levy PY, Fournier PE, Charrel R, et al. Molecular analysis of pericardial fluid: a 7-year experience. Eur Heart J. 2006;27(16):1942-1946.
  13. 13.Fallek Boldes O, Dahan S, Segal Y, et al. Characteristics of pericardial biopsy: 100 cases in a single center. Isr Med Assoc J. 2019;21(3):183-188.
  14. 14.Sathirareuangchai S, Kobayashi M, Shimizu D. Etiologies of pericarditis in hospital and forensic autopsies. Cardiovasc Pathol. 2020;49:107262.
  15. 15.Ariyarajah V, Spodick DH. Acute pericarditis: diagnostic cues and common electrocardiographic manifestations. Cardiol Rev. 2007;15(1):24-30.
  16. 16.Reuter H, Burgess LJ, Doubell AF. Epidemiology of pericardial effusions at a large academic hospital in South Africa. Epidemiol Infect. 2005;133(3):393-399.
  17. 17.Lazarou E, Tsioufis P, Vlachopoulos C, et al. Acute pericarditis: update. Curr Cardiol Rep. 2022;24(8):905-913.
  18. 18.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.
  19. 19.Henzler T, Roeger S, Meyer M, et al. Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction. Eur Respir J. 2012;39(4):919-926.
  20. 20.Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121(7):916-928.
  21. 21.Hooper AJ, Celenza A. A descriptive analysis of patients with an emergency department diagnosis of acute pericarditis. Emerg Med J. 2013;30(12):1003-1008.
  22. 22.Radovanovic M, Petrovic M, Hanna RD, et al. Clinical presentation and management of methicillin-resistant Staphylococcus aureus pericarditis-systematic review. J Cardiovasc Dev Dis. 2022;9(4):103.
  23. 23.Spodick DH. Pericardial rub. Prospective, multiple observer investigation of pericardial friction in 100 patients. Am J Cardiol. 1975;35(3):357-362.
  24. 24.Prepoudis A, Koechlin L, Nestelberger T, et al.; APACE investigators. Incidence, clinical presentation, management, and outcome of acute pericarditis and myopericarditis. Eur Heart J Acute Cardiovasc Care. 2022;11(2):137-147.
  25. 25.Spodick DH. Diagnostic electrocardiographic sequences in acute pericarditis. Significance of PR segment and PR vector changes. Circulation. 1973;48(3):575-580.
  26. 26.Ginzton LE, Laks MM. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation. 1982;65(5):1004-1009.
  27. 27.Imazio M, Brucato A, Maestroni S, et al. Prevalence of C-reactive protein elevation and time course of normalization in acute pericarditis: implications for the diagnosis, therapy, and prognosis of pericarditis. Circulation. 2011;123(10):1092-1097.
  28. 28.Yılmaz F, Yılmaz FK, Karagöz A, et al. Usefulness of neutrophil-to-lymphocyte ratio for predicting acute pericarditis outcomes. Acta Cardiol. 2022;77(5):422-430.
  29. 29.Imazio M, Demichelis B, Cecchi E, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003;42(12):2144-2148.
  30. 30.Bonnefoy E, Godon P, Kirkorian G, et al. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000;21(10):832-836.
  31. 31.Machado S, Roubille F, Gahide G, et al. Can troponin elevation predict worse prognosis in patients with acute pericarditis?. Ann Cardiol Angeiol (Paris). 2010;59(1):1-7.
  32. 32.Hammer MM, Raptis CA, Javidan-Nejad C, et al. Accuracy of computed tomography findings in acute pericarditis. Acta Radiol. 2014;55(10):1197-1202.
  33. 33.Cremer PC, Kumar A, Kontzias A, et al. Complicated pericarditis: understanding risk factors and pathophysiology to inform imaging and treatment. J Am Coll Cardiol. 2016;68(21):2311-2328.
  34. 34.Lexicomp. Wolters Kluwer; 2023. Accessed May 4, 2023. https://www.wolterskluwer.com/en/solutions/lexicomp
  35. 35.Imazio M, Brucato A, Belli R, et al. Colchicine for the prevention of pericarditis: what we know and what we do not know in 2014–systematic review and meta-analysis. J Cardiovasc Med (Hagerstown). 2014;15(12):840-846.
  36. 36.Alabed S, Cabello JB, Irving GJ, et al. Colchicine for pericarditis. Cochrane Database Syst Rev. 2014(8):CD010652.
  37. 37.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;383(9936):2232-2237.
  38. 38.Imazio M, Brucato A, Forno D, et al. Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. Heart. 2012;98(14):1078-1082.
  39. 39.Imazio M, Lazaros G, Brucato A, et al. Recurrent pericarditis: new and emerging therapeutic options. Nat Rev Cardiol. 2016;13(2):99-105.
  40. 40.Brucato A, Brambilla G, Moreo A, et al. Long-term outcomes in difficult-to-treat patients with recurrent pericarditis. Am J Cardiol. 2006;98(2):267-271.
  41. 41.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;316(18):1906-1912.
  42. 42.Klein AL, Imazio M, Cremer P, et al.; RHAPSODY Investigators. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis. N Engl J Med. 2021;384(1):31-41.
  43. 43.Vianello F, Cinetto F, Cavraro M, et al. Azathioprine in isolated recurrent pericarditis: a single centre experience. Int J Cardiol. 2011;147(3):477-478.
  44. 44.Imazio M, Lazaros G, Picardi E, et al. Intravenous human immunoglobulins for refractory recurrent pericarditis: a systematic review of all published cases. J Cardiovasc Med (Hagerstown). 2016;17(4):263-269.
  45. 45.Pelliccia A, Solberg EE, Papadakis M, et al. Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2019;40(1):19-33.
  46. 46.Imazio M, Brucato A, Cemin R, et al.; ICAP Investigators. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.
  47. 47.Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011;124(11):1270-1275.
  48. 48.Imazio M, Brucato A, Adler Y, et al. Prognosis of idiopathic recurrent pericarditis as determined from previously published reports. Am J Cardiol. 2007;100(6):1026-1028.
  49. 49.Tingle LE, Molina D, Calvert CW. Acute pericarditis. Am Fam Physician. 2007;76(10):1509-1514.
  50. 50.Goyle KK, Walling AD. Diagnosing pericarditis. Am Fam Physician. 2002;66(9):1695-1702.
  51. 51.Marinella MA. Electrocardiographic manifestations and differential diagnosis of acute pericarditis. Am Fam Physician. 1998;57(4):699-704.
Previous article
Substance Misuse in Adults: A Primary Care Approach
May 2024
Next article
Falls in Older Adults: Approach and Prevention

Current issue

September 2026

September 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.