What are the signs and symptoms of pericarditis?

Signs and Symptoms of Pericarditis

Acute pericarditis is diagnosed when at least 2 of 4 cardinal features are present: characteristic chest pain, pericardial friction rub, specific ECG changes, or pericardial effusion. 1

Cardinal Diagnostic Features

Chest Pain (Present in ~90% of cases)

• Sharp, pleuritic chest pain that is retrosternal or left precordial in location 1, 2, 3
• Radiates to the trapezius ridge (highly characteristic feature), neck, back, or left shoulder 1, 4, 2
• Positional variation: worsens when lying supine and improves when sitting up or leaning forward 2, 3
• Can simulate myocardial ischemia in some cases, making differentiation from acute coronary syndrome critical 1, 4
• May have pleuritic quality (worsens with inspiration) 2, 5

Pericardial Friction Rub (Present in <30% of cases)

• Highly specific but transient scratching or squeaking sound on auscultation 4, 2, 3
• Can be mono-, bi-, or triphasic in character 1, 2
• Best heard with patient sitting upright and leaning forward while briefly holding their breath 4
• May disappear and reappear during the disease course, requiring repeated examinations 4
• Can persist even with large effusions 1

ECG Changes (Present in 25-60% of cases)

• Widespread concave ST-segment elevation (anterior and inferior leads: I, II, aVL, aVF, V3-V6) 1
• PR-segment depression (opposite to P wave polarity) 1, 2
• ST depression always present in aVR, frequently in V1 1
• Changes evolve through 4 stages, though this temporal evolution is highly variable 1
• Key distinction from MI: widespread distribution without reciprocal changes, concave (not convex) ST elevation 4, 2

Pericardial Effusion (Present in ~60% of cases)

• New or worsening effusion detected on echocardiography 1, 2
• Absence of effusion does not exclude pericarditis 4
• Chest X-ray only shows cardiomegaly when effusion exceeds 300 mL 1

Associated Clinical Features

Constitutional Symptoms

• Prodrome of fever, malaise, and myalgia is common 1
• Elderly patients may not be febrile despite active inflammation 1
• Rapid and regular heart rate 1

Laboratory Findings (Supporting Evidence)

• Elevated inflammatory markers: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count 1, 2
• These markers are helpful for monitoring disease activity and treatment response 1
• Elevated cardiac troponins (detectable in up to 49-50% of cases) indicate myopericarditis, not myocardial infarction 1
• When troponin is elevated with ST elevation on ECG, the term "perimyocarditis" applies 1, 4

Additional Physical Findings

• Shortness of breath (dyspnea) 1, 6
• Pleural effusion may be present 1
• New S3 heart sound suggests myocardial involvement 1

Critical Pitfalls to Avoid

• Do not rely on a single finding: The diagnosis requires at least 2 of the 4 cardinal criteria 1, 2
• Friction rub is highly specific but often absent: Only present in <30% of cases and can be transient 4, 2, 3
• Normal echocardiogram does not exclude pericarditis: Effusion is only present in 60% of cases 4
• ECG changes may be absent: Typical changes occur in only 25-60% of patients 1, 3
• Elevated troponin indicates myopericarditis, not MI: This occurs in up to 50% of pericarditis cases and does not change the favorable prognosis 1, 4
• Differentiate from acute MI: Pericarditis shows widespread concave ST elevation without reciprocal changes, while MI shows localized convex ST elevation 4, 2
• Left arm pain is atypical: This suggests possible myocardial involvement or acute coronary syndrome rather than isolated pericarditis 4

Imaging Findings

• Transthoracic echocardiography is essential in all suspected cases to detect effusion and assess for complications 1, 4, 2
• CT and cardiac MRI can detect pericardial inflammation, thickening (>3 mm), and help differentiate from other conditions 1, 4
• Pericardial thickening may be present in some cases 4