Last updated: September 11, 2023

Summarytoggle arrow icon

Pericarditis is inflammation of the pericardium and may be acute or chronic. Acute pericarditis is most commonly caused by a viral infection; however, a number of conditions can cause an inflammatory response in the pericardium. Acute pericarditis typically manifests with low-grade fever, pleuritic chest pain, and a pericardial friction rub on auscultation. The diagnosis is established based on clinical findings, although diffuse ST segment elevations on ECG and imaging may support the diagnosis. Acute pericarditis is usually self-limited, lasting days to weeks, and is therefore managed symptomatically. If pericarditis lasts longer than 3 months, it is described as chronic pericarditis. Chronic pericarditis is typically either constrictive or effusive-constrictive. Constrictive pericarditis is characterized by thickening and rigidity of the pericardium, resulting in both backward and forward failure. Patients typically present with fatigue, jugular vein distention, peripheral edema, and a characteristic pericardial knock on auscultation, which is caused by a sudden stop in ventricular diastolic filling. Effusive-constrictive pericarditis is characterized by a thickened pericardium with an effusion; this can lead to cardiac tamponade. It may manifest with symptoms similar to constrictive pericarditis, symptoms of pericardial effusion, or cardiac tamponade. In both constrictive and effusive-constrictive pericarditis, imaging is used to confirm the diagnosis. Management consists of treatment of heart failure (e.g., diuretics) and pericardiectomy.

Definitiontoggle arrow icon

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

Acute pericarditis [8]

Acute pericarditis classically presents with sharp, retrosternal chest pain that is exacerbated by deep inspiration and lessened by sitting up or leaning forward. [13][14]

Chronic pericarditis

Constrictive pericarditis [5][8]

The majority of patients with constrictive pericarditis present with symptoms of heart failure (predominantly dyspnea on exertion and edema). [15]

Effusive-constrictive pericarditis [4]

Effusive-constrictive pericarditis is characterized by symptoms of chronic constrictive pericarditis, pericardial effusion, or a mixture of both.

  • Smaller or slow-growing effusions: Patients may be asymptomatic.
  • Large effusions or rapidly growing effusions: symptoms of cardiac tamponade

Subtypes and variantstoggle arrow icon

Purulent pericarditis

Diagnosticstoggle arrow icon

Acute pericarditis [5]


  • Check ECG, TTE to determine if diagnostic criteria are met.
  • If TTE is inconclusive, consider CT or cardiac MRI to confirm pericardial inflammation/effusion.
  • Determine whether any further diagnostic evaluation is indicated based on suspected etiology (see “Additional diagnostic evaluation” below).

Rule out other causes of acute chest pain (e.g., myocardial infarction, myocarditis) before making a diagnosis of acute pericarditis. [14]

Diagnostic criteria for acute pericarditis [4]

At least two of the following four criteria must be present for a diagnosis of acute pericarditis:

  1. Characteristic chest pain
  2. Pericardial friction rub
  3. Typical ECG changes (see below)
  4. New or worsening pericardial effusion

ECG features of pericarditis

Not all patients go through all stages and manifestations may vary. In particular, pericarditis due to uremia may not involve characteristic ECG changes. [16]

In contrast to myocardial infarction, pericarditis is characterized by a diffuse distribution of ST elevations on ECG.See also “Differential diagnoses of ST elevations on ECG.”

Imaging [4][5]

The goal of imaging is to identify any new pericardial effusion and rule out alternative etiologies.

Echocardiography is often normal in patients with pericarditis but is needed to rule out pericardial tamponade and pericardial constriction. [14]

Cardiac tamponade can occur with relatively small pericardial effusions if pericardial fluid accumulation is rapid. [18]

Laboratory studies

Elevation of inflammatory markers may support the diagnosis of pericarditis but are not considered to be a part of the diagnostic criteria. [4]

Troponin elevation is not predictive of negative outcomes in pericarditis but does suggest some degree of myocarditis. Significant elevation should raise concern for acute coronary syndrome. [19]

Additional diagnostic evaluation

Chronic pericarditis

The diagnostic approach and findings for chronic pericarditis are similar to acute pericarditis but ECG, echocardiography, and imaging findings may vary.

Constrictive pericarditis [5][8]

The diagnosis of constrictive pericarditis is based on characteristic imaging findings (most commonly echocardiography but MRI and CT may be used).

Effusive-constrictive pericarditis

The diagnostic findings of effusive-constrictive pericarditis are similar to those of pericardial effusion, with the exception that in addition to pericardial effusion, pericardial thickening may also be seen. Elevation of right atrial pressures despite pericardiocentesis is strongly suggestive of effusive-constrictive. [25]

Treatmenttoggle arrow icon

The mainstays of therapy include anti-inflammatories to control pain and prevent a recurrence, and treatment of the underlying cause (if found).

Medical therapy

Acute pericarditis is often self-limited but NSAIDs can alleviate symptoms and prevent a recurrence. Consider anti-inflammatory therapy also for chronic pericarditis (transient constrictive pericarditis may respond). [12]


Supportive therapy

Special circumstances [14]

Administration of sedatives and/or the initiation of positive pressure ventilation may precipitate hemodynamic collapse in patients with constrictive pericarditis or effusive-constrictive pericarditis. [32][33]

Beta blockers and calcium channel blockers should be avoided in constrictive pericarditis, as they may worsen heart failure by slowing a compensatory tachycardia!

Surgical therapy

Disposition [4][8][12][35]

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

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