What are the symptoms of pericarditis in a patient, potentially with a history of autoimmune disorders, cancer, or previous heart surgery?

Symptoms of Pericarditis

The cardinal symptom of pericarditis is sharp, retrosternal or left precordial chest pain that radiates to the trapezius ridge, worsens with lying flat or inspiration, and improves when sitting up and leaning forward. 1

Primary Clinical Features

Chest Pain Characteristics

• Sharp, pleuritic chest pain located in the retrosternal or left precordial region that can radiate to the left shoulder and trapezius ridge 1, 2
• Pain varies with posture—relieved by sitting up and leaning forward, worsened by lying supine 1, 3
• Can simulate ischemic pain, making differentiation from acute coronary syndrome critical 1
• Pleuritic quality means pain worsens with deep breathing or coughing 2, 4

Constitutional Symptoms

• Fever, malaise, and myalgia commonly precede the chest pain as a prodromal phase 1
• Important caveat: Elderly patients may not be febrile despite active pericarditis 1
• Symptoms often follow or occur with acute respiratory illness (tonsillitis, pneumonia) or gastroenteritis 1

Physical Examination Findings

• Pericardial friction rub is the pathognomonic finding, heard in up to 85% of patients 1, 4, 3
• The rub can be mono-, bi-, or triphasic and may be transient 1
• Best auscultated at the left lower sternal border with the patient leaning forward 4
• Heart rate is usually rapid and regular 1

Associated Symptoms

Respiratory Symptoms

• Shortness of breath is a major symptom, particularly when effusion is present 1
• Pleural effusion may coexist, causing additional pleuritic symptoms 1

Symptoms Suggesting Complications

• Syncope or near-syncope may indicate cardiac tamponade or, rarely, herniation through congenital pericardial defects 1
• Decreased blood pressure, elevated jugular venous pressure, and muffled heart sounds suggest tamponade 4
• Pulsus paradoxus (>10 mmHg drop in systolic BP with inspiration) indicates hemodynamic compromise 4

Diagnostic Criteria

At least 2 of the following 4 criteria establish the diagnosis of acute pericarditis: 1

1. Pericarditic chest pain (as described above)
2. Pericardial friction rub on auscultation
3. New widespread ST-elevation or PR depression on ECG
4. Pericardial effusion (new or worsening)

Context-Specific Presentations

In Autoimmune Disorders

• Pericarditis occurs as part of systemic autoimmune diseases like systemic lupus erythematosus or rheumatoid arthritis 1
• May present with less prominent chest pain and more systemic inflammatory symptoms 1

Post-Cardiac Surgery or Trauma

• Post-cardiac injury syndromes present with fever, pericarditic or pleuritic chest pain, and evidence of inflammation after a latent period of several weeks 1
• Requires at least 2 of 5 criteria: fever without alternative cause, pericarditic/pleuritic pain, pericardial/pleural rubs, pericardial effusion, or pleural effusion with elevated CRP 1

In Cancer Patients

• Neoplastic pericarditis may have more insidious onset with less prominent pain 1
• Higher risk of large effusions and tamponade 1

Important Clinical Pitfalls

• Do not dismiss atypical presentations: Some patients, especially elderly, may lack fever or have minimal pain 1
• Distinguish from acute coronary syndrome: Pericarditis pain is positional and pleuritic, while ischemic pain is not; however, both can present with ST-elevation on ECG 1, 3
• Myopericarditis presents with elevated troponins but maintains the clinical features of pericarditis with added markers of myocardial injury 1
• Pericardial friction rub can be transient—absence does not exclude pericarditis if other criteria are met 1