Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Airway, breathing, circulation threats
Hemodynamic instability
SBP < 90 mmHg
Sinus tachycardia out of proportion to fever
Tamponade physiology
Pulsus paradoxus > 10 mmHg
Elevated JVP with clear lungs
Oxygenation and ventilation
SpO2 target 94% to 98%
Work of breathing from large effusion
Cardiac tamponade recognition
Beck triad
Hypotension
Distended neck veins
Muffled heart sounds
If tamponade with shock, emergent pericardiocentesis
Echo guidance preferred
IV fluid bolus as temporizing bridge
Avoid aggressive diuresis or preload reduction
Worsens forward flow in tamponade
Maintain preload until drainage
Key early branching
Uncomplicated acute pericarditis
No effusion or small effusion
Hemodynamically stable
Complicated pericarditis
Large effusion > 2.0 cm
Concomitant myocarditis
If diffuse ST elevation, exclude STEMI before anti-inflammatory therapy
Compare ECG morphology
Serial troponin
Monitoring and targets
Monitoring bundle
Continuous cardiac telemetry
Atrial fibrillation or flutter in about 4%
Electrical alternans with large effusion
Serial blood pressure
Manual pulsus paradoxus measurement
Trend for tamponade evolution
Reassessment cadence
Response to anti-inflammatory within hours
Symptom trajectory over first day
Escalation triggers
Evolving tamponade
Rising heart rate
Falling SBP after fluids
Concomitant myocarditis
New troponin rise with LV dysfunction
Ventricular arrhythmia
Refractory chest pain
Reassess diagnosis
Consider alternative life threat
Immediate consults
Consultation triggers
Cardiology
Tamponade or large effusion
Myopericarditis or recurrent disease
Cardiothoracic surgery
Purulent pericarditis requiring drainage
Constrictive physiology for pericardiectomy
Specialty etiology workup
Rheumatology for autoimmune cause
Infectious disease for TB or bacterial cause
History
Presentation pattern
Core chest pain syndrome
Sharp pleuritic retrosternal pain
Worse supine
Improved sitting up and leaning forward
Radiation to trapezius ridge
Virtually pathognomonic
Reflects phrenic nerve involvement
Onset and timing
Often abrupt over hours
Constant or intermittent course
Associated symptoms
Constitutional features
Low-grade fever and malaise
Fatigue
Respiratory overlap
Dyspnea
Cough
Prodrome
Viral URI 1 to 3 weeks prior
Recent gastroenteritis
Risk factors
Personal risk factors
Demographics
Male sex
Young to middle age
Recent triggers
Viral illness as most common trigger
Recent cardiac surgery or catheterization
Comorbid conditions
Autoimmune disease such as SLE or RA
Uremia or end-stage renal disease
Etiologic exposures
Infectious exposures
TB exposure in endemic areas
HIV or immunosuppression
Malignancy
Lung, breast, lymphoma, leukemia
Prior chest radiation therapy
Drug-induced
Hydralazine or procainamide
Isoniazid
Family and social history
Family history
Familial Mediterranean fever
Autoimmune disease
Social context
Immigration from TB-endemic region
Incarceration or homelessness
Alarm features
High-risk historical clues
Fever > 38.5 C
Suggests bacterial, TB, or autoimmune cause
Prompts admission and broader workup
Subacute insidious onset
Symptoms over days without clear onset
Higher complication risk
Failure to respond to NSAIDs within 1 week
Predicts complicated course
Reconsider etiology
Important negatives to exclude mimics
Exertional component suggesting ACS
Crescendo pattern
Relief with rest
Tearing pain suggesting dissection
Radiation to back
Migrating quality
Unilateral pleuritic pain with leg swelling suggesting PE
Calf tenderness
Immobilization history
Physical Exam
Vitals and general
Stability snapshot
Temperature
Low-grade fever common
High fever > 38.5 C as red flag
Heart rate
Sinus tachycardia typical
Irregular rhythm suggesting atrial fibrillation
Blood pressure
SBP < 90 mmHg as shock marker
Pulsus paradoxus > 10 mmHg
General appearance
Positional comfort
Leaning forward for relief
Distress when supine
Systemic illness signs
Pallor or diaphoresis
Toxic appearance with bacterial cause
Cardiac and hemodynamic exam
Pericardial friction rub
Acoustic character
High-pitched scratchy quality
Triphasic atrial systole, ventricular systole, early diastole
Auscultation technique
Diaphragm at left lower sternal border
Patient leaning forward in end-expiration
Limitations
Present in under 30% of cases
Transient and may vary hour to hour
Tamponade and constriction signs
Beck triad components
Hypotension
Jugular venous distension
Muffled heart sounds
Pulsus paradoxus
> 10 mmHg inspiratory SBP drop
Manual cuff measurement
Kussmaul sign
JVP rise with inspiration
Suggests constrictive physiology
PITFALLS
Examination caveats
Absent friction rub does not exclude diagnosis
Rub present in minority
Re-auscultate over time
Misreading tamponade as sepsis
Tachycardia and hypotension overlap
Bedside echo to differentiate
Systemic disease screen
Autoimmune signs
Joint swelling and rashes
Oral ulcers
Lymphadenopathy
Malignancy concern
TB concern
Differential Diagnosis
Life threats and close mimics
Immediate threats
Acute coronary syndrome or STEMI
ICD-10 I21.3 ST elevation MI
Regional ST elevation with reciprocal changes
Aortic dissection
ICD-10 I71.00
Tearing pain with pulse or BP differential
Pulmonary embolism
ICD-10 I26.99
Pleuritic pain with right heart strain
Cardiac mimics
Myocarditis
Troponin rise with LV dysfunction
Concomitant myopericarditis in about 15%
Cardiac tamponade
ICD-10 I31.4
Complication of pericarditis itself
Early repolarization
Concave ST elevation in young patients
ST to T ratio < 0.25 in V6
Non-cardiac mimics
Pneumonia or pleuritis
Fever with productive cough
Focal lung findings
Pneumothorax
Sudden unilateral decreased breath sounds
Hyperresonance
Costochondritis
Reproducible chest wall tenderness
No systemic features
GERD or esophageal spasm
Burning meal-related pain
Response to antacids
Differentiating clues
Pericarditis versus STEMI on ECG
Distribution
Diffuse rather than territorial ST elevation
No pathologic Q waves
Morphology
Concave saddleback ST shape
Convex ST shape favors STEMI
Supportive findings
PR depression diffuse with PR elevation in aVR
ST to T ratio > 0.25 in V6
Laboratory Tests
Inflammatory markers
Inflammation panel
C-reactive protein
Elevated in about 78%
Guides treatment response and NSAID taper
Erythrocyte sedimentation rate
Supports inflammatory phenotype
Trends with disease activity
Complete blood count with differential
Neutrophilic leukocytosis supports inflammation
Lymphopenia in some viral causes
Cardiac and organ function
Myocardial markers
Troponin
Elevated in about 30%
Elevation without LV dysfunction defines myopericarditis
Not a negative prognostic marker in isolated pericarditis
BNP or NT-proBNP
Generally normal in isolated pericarditis
Elevation suggests myocardial involvement or HF
Metabolic panel
Basic metabolic panel
Baseline renal function before NSAIDs
Exclude uremia as cause
Glucose
Baseline before corticosteroids
Stress hyperglycemia marker
Selective high-risk workup
Etiology-directed testing
Antinuclear antibody
Only with clinical suspicion of autoimmune disease
Low-level titers are nonspecific
TB testing
PPD or IGRA when risk factors present
Endemic exposure or immunosuppression
Blood cultures
When bacterial pericarditis suspected
Before antibiotics when feasible
Additional targeted tests
HIV testing
When risk factors present
Immunocompromise workup
TSH
When hypothyroidism suspected
Myxedema pericarditis is rare
Serial CRP for monitoring
Guides NSAID taper timing
Detects recurrence
Diagnostic Tests
Scoring Systems
High-risk feature stratification
Major poor-prognosis criteria
Fever > 38 C
Subacute onset
Large effusion > 2.0 cm or tamponade
Failure to respond to NSAIDs within 1 week
Minor poor-prognosis criteria
Myopericarditis
Immunosuppression
Trauma
Oral anticoagulant therapy
Interpretation
Any major or minor feature favors admission
Absence of all features supports outpatient care
ECG staging system
Four classic stages
Stage I diffuse concave ST elevation with PR depression
Stage II ST normalizes and T waves flatten
Stage III diffuse T-wave inversions
Stage IV ECG normalizes
Diagnostic yield
ECG changes in 25% to 60% of cases
Spodick sign of downsloping TP segment
Diagnostic criteria
Requires 2 of 4 features
Characteristic pleuritic chest pain
Pericardial friction rub
Diffuse ST elevation or PR depression
New or worsening pericardial effusion
Supportive findings
Elevated inflammatory markers
Pericardial inflammation on imaging
MRI
Cardiac MRI role
Indications
Complicated, recurrent, or indeterminate cases
Suspected concomitant myocarditis
Findings
Pericardial late gadolinium enhancement indicating inflammation
Pericardial edema and thickening
Interpretation pearls
Severe pericardial LGE predicts recurrence
Distinguishes active from chronic disease
Practical considerations
Contraindications
Hemodynamic instability
Non-compatible implants
Access and guidance
Limited acute availability
Recommended in expert consensus for complex disease
CT
Cardiac CT indications
Preferred uses
Pericardial calcification in constriction
Evaluation of pericardial masses
Findings
Pericardial thickening > 4 mm
Calcified pericardium
Adjunct role
Exclude PE or dissection when mimic suspected
Characterize loculated effusion
Guidance and limits
Not recommended for routine assessment
Reserve for complicated cases
Avoid routine CT in uncomplicated pericarditis
Contrast considerations
Renal function assessment
Allergy history
Ultrasound
Transthoracic echocardiography
Recommended in all patients
Effusion size quantification
LV function assessment
Tamponade physiology
RV diastolic collapse
IVC plethora with reduced respiratory variation
Constrictive features
Septal bounce
Respirophasic septal shift
Point-of-care ultrasound
ED rapid assessment
Identify hemodynamically significant effusion
RV diastolic collapse for tamponade
Procedural guidance
Echo-guided pericardiocentesis
Optimal needle entry site selection
Limitations
Operator dependence
Loculated effusion may be missed
Disposition
Level of care selection
Admission indications
High-risk clinical features
Fever > 38 C
Subacute insidious course
Effusion and hemodynamics
Large effusion > 2.0 cm or tamponade
Hemodynamic instability
Treatment and host factors
Failure to respond to NSAIDs after 1 week
Oral anticoagulant use with hemorrhagic effusion risk
ICU indications
Tamponade requiring intervention
Pericardiocentesis with hemodynamic monitoring
Vasoactive support
Concomitant myocarditis with dysfunction
LV dysfunction
Ventricular arrhythmia
Suspected purulent pericarditis
Septic physiology
Source control planning
Discharge criteria and follow up
Outpatient criteria
Low-risk profile
No major or minor risk features
Small or no effusion
Treatment response
Responsive to initial NSAID therapy
Hemodynamically stable
Reliable safety net
Reliable follow-up available
Understands return precautions
Follow up plan
Clinical reassessment
1 to 2 weeks after discharge
Repeat CRP to guide taper
Imaging follow up
Repeat echocardiography if effusion present
At completion of colchicine course
Specialist referral
Cardiology for recurrent or complicated disease
Rheumatology when autoimmune cause suspected
Treatment
Initial stabilization
Resuscitation measures
Standard supportive care
IV access and continuous monitoring if unstable
Supplemental oxygen to SpO2 target 94% to 98%
Tamponade management
Emergent pericardiocentesis for tamponade
IV fluid bolus as temporizing measure
If purulent pericarditis, surgical drainage and antibiotics
Broad-spectrum coverage pending cultures
Cardiothoracic surgery involvement
First-line pharmacotherapy
NSAID therapy
Ibuprofen regimen
Ibuprofen 600 to 800 mg PO every 8 hours
Total 1600 to 2400 mg per day
Taper 200 to 400 mg every 2 to 4 weeks after symptom and CRP resolution
Aspirin alternative
Aspirin 650 to 1000 mg PO three times daily
Preferred with concomitant coronary artery disease
Taper after symptom resolution
Gastroprotection
Proton pump inhibitor with NSAID therapy
Take NSAIDs with food
Colchicine therapy
Weight-based dosing
Colchicine 0.5 mg twice daily if > 70 kg
Colchicine 0.5 mg once daily if 70 kg or less
Duration
3 months for first episode
6 months or more for recurrence
Benefits and cautions
Reduces recurrence by about 50%
Dose-reduce with P-gp or CYP3A4 inhibitors
GI intolerance is common
Second-line and refractory therapy
Corticosteroids
Indication
NSAID and colchicine failure or contraindication
Specific etiologies such as autoimmune disease
Dosing
Prednisone 0.2 to 0.5 mg/kg/day low-to-medium dose
Slow taper guided by CRP
Cautions
Early use increases recurrence risk
Add colchicine to reduce steroid-related recurrence
IL-1 blockers
Indication
Multiple recurrences with inflammatory phenotype
CRP > 10 mg/L refractory to colchicine and steroids
Agents
Anakinra
Rilonacept
Monitoring
Injection-site reactions
Infection surveillance
Contraindications and precautions
Medication safety
Anticoagulant caution
Avoid if possible due to hemorrhagic effusion risk
Reassess indication when effusion present
NSAID precautions
Caution in CKD and heart failure
Avoid in peptic ulcer disease and bleeding diathesis
Adequate hydration
Renal protection with NSAIDs
Avoid alcohol during acute illness
Activity and adjuncts
Exercise restriction
Restriction duration
At least 1 month until clinical remission
Keep maximal heart rate < 100 bpm
Return to activity
After symptom resolution and CRP normalization
Longer restriction with myopericarditis
Monitoring response
Serial CRP
Do not taper until CRP normalizes
Detect early recurrence
If no response in 1 week, reconsider etiology
Broaden workup
Escalate therapy
Special Populations
Pregnancy
Pregnancy considerations
Medication safety by trimester
NSAIDs acceptable before 20 weeks
Avoid NSAIDs after 20 weeks due to ductal and renal risk
Colchicine use
Generally continued in familial Mediterranean fever
Shared decision-making for pericarditis
Corticosteroid role
Low-dose prednisone often preferred later in pregnancy
Monitor maternal glucose and blood pressure
Imaging approach
Echocardiography as first-line, no radiation
CT only when benefits outweigh fetal risk
Geriatric
Older adult features
Atypical presentation
Less prominent positional pain
Higher proportion with effusion
Etiology shift
Higher malignancy and uremic causes
Lower idiopathic proportion
Medication risk
NSAID caution with renal impairment and heart failure
Colchicine dose reduction with renal impairment
Disposition bias
Lower threshold for admission
Comorbidity decompensation risk
Pediatrics
Pediatric differences
Etiology
Predominantly viral or idiopathic
Post-cardiac injury after congenital surgery
Weight-based dosing
Ibuprofen 10 mg/kg PO every 8 hours
Colchicine 0.5 mg per day weight-adjusted
Aspirin caution
Reye syndrome risk in viral illness
Reserve aspirin for specific indications
Monitoring
Activity restriction during acute phase
Serial inflammatory markers
Background
Epidemiology
Frequency and burden
ED presentation
About 4.4% of nonischemic chest pain in the ED
More common in men aged 16 to 65
Etiology distribution
Idiopathic or viral in 80% to 90%
TB leading cause in endemic regions
Complication rates
Recurrence in 15% to 30%
Cardiac tamponade in under 3%
Constrictive pericarditis in under 0.5%
Pathophysiology
Mechanisms
Pericardial inflammation
Visceral and parietal layer irritation
Friction rub from inflamed surfaces
Effusion formation
Exudative fluid accumulation
Tamponade when intrapericardial pressure exceeds filling pressure
Phenotypes
Inflammatory in 80% to 90% with elevated CRP
Noninflammatory in 10% to 20% often autoimmune-associated
Myocardial involvement
Concomitant myocarditis in about 15%
Troponin elevation with possible LV dysfunction
Therapeutic Considerations
Treatment strategy principles
Dual therapy rationale
NSAID plus colchicine reduces recurrence
Colchicine halves recurrence risk
Steroid-sparing approach
Avoid early corticosteroids when possible
Reserve steroids for refractory or specific etiologies
Taper guided by biomarkers
Taper only after CRP normalizes
Serial CRP detects recurrence
Prognosis and natural history
Benign course
Benign in 70% to 85% with treatment
Most resolve within 1 to 2 weeks
Recurrence risk
Up to 50% after first recurrence
Severe LGE on CMR predicts recurrence
Evidence base
ICAP and CORP trials support colchicine
IL-1 blockade for refractory recurrent disease
Patient Discharge Instructions
copy discharge instructions
Acute pericarditis home care
Take all medications exactly as prescribed
Do not stop colchicine early as it prevents recurrence
Take anti-inflammatory medicine with food
Rest and limit strenuous activity for at least 1 month
Warning signs to return to ER
Worsening chest pain not relieved by medication
New or worsening shortness of breath
Trouble breathing when lying flat
Lightheadedness, fainting, or near-fainting
Fever above 38 C
New leg swelling
Follow up
Clinic follow up within 1 to 2 weeks
Repeat blood test to guide medication taper
Repeat heart ultrasound if fluid was present
Activity and recovery tips
Avoid vigorous exercise until cleared
Keep heart rate under 100 during activity
Avoid alcohol during recovery
Most people recover within 1 to 2 weeks
References
Guidelines and key sources
Guideline sources
2025 ACC Expert Consensus on diagnosis and management of pericarditis
2021 AHA ACC chest pain evaluation guideline
AAFP rapid evidence review on acute pericarditis
Landmark trials and reviews
ICAP and CORP colchicine trials for recurrence prevention
JAMA 2024 review on diagnosis, risk stratification, and treatment
NEJM 2014 review of acute pericarditis
Coding standards
ICD-10 I30.9 acute pericarditis unspecified
ICD-10 I31.4 cardiac tamponade
SNOMED CT acute pericarditis disorder concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.