Etiology

Idiopathic
Infectious
- Most commonly viral (e.g., coxsackie B virus)
- Bacterial (e.g., Staphylococcus spp., Streptococcus spp., or M. tuberculosis)
Myocardial infarction
- Postinfarction fibrinous pericarditis: within 1–3 days as an immediate reaction
- Dressler syndrome: weeks to months after an acute myocardial infarction
Postoperative (postpericardiotomy syndrome): due to blunt or sharp trauma to the pericardium
Uremia: e.g., due to acute or chronic renal failure
- Accumulated toxins promote inflammation.
Radiation
- Exudative pericarditis: develops acutely during or after radiation therapy
- Constrictive pericarditis: develops several years after radiation therapy
Neoplasms (e.g., Hodgkin lymphoma)
Autoimmune connective tissue diseases (e.g., rheumatoid arthritis, SLE, scleroderma)
Trauma

Classifications

Serous Pericarditis
- Viral infection (Coxsackievirus, echovirus, adenovirus)
- Uremia
- TB pericarditis (early stage)
- Rheumatic fever
- Malignancy involvement
- SLE, Rheumatoid arthritis
Fibrous or Fibrinous Pericarditis
- Most common pericarditis
- MI (Dressler syndrome)
- Rheumatic fever
- Uremia
- TB pericarditis
- Malignancy involvement
- Pericardial surface covered by shaggy, fibrinous exudate
- “Bread and Butter” appearance
Purulent (Suppurative) Pericarditis
- Pyogenic bacteria (Staphylococci, Streptococci, Pneumococci)
- Direct extension / hematogenous or lymphatic spread / direct implant
- Severe acute infection
- Pericardial surface covered by purulent exudate and infiltrated by neutrophils
Hemorrhagic Pericarditis
- Malignancy involvement
- TB pericarditis
- Severe acute infection
- Admixture of inflammatory effusion with blood

Chest Pain (CP): Pleuritic, sharp, retrosternal.
Positional: Worse when supine; relieved by leaning forward.
Radiation: Trapezius ridges (pathognomonic; phrenic nerve irritation).
Physical Exam (PE): Pericardial Friction Rub (high-pitched, scratching/velcro sound; heard best at LLSB with pt leaning forward during expiration).

Symptoms of fluid overload (i.e., backward failure)
- Jugular vein distention, ↑ jugular venous pressure
  - Won’t seen in cirrhosis
Kussmaul Sign: Paradoxical rise in JVD with inspiration (impaired RV filling).
Pericardial Knock: High-frequency early diastolic sound (caused by sudden cessation of ventricular filling). c
- Differ from S3, which is low-frequency early diastolic sound

Clinical Dx: Requires ≥2 of 4: (1) Characteristic CP, (2) Friction rub, (3) EKG changes, (4) New/worsening pericardial effusion.
Initial/Screening (EKG):
- Diffuse ST-elevation (concave/up-sloping) and PR-segment depression (highly specific). c
- Note: aVR will show ST-depression and PR-elevation.
Key Labs: ↑ ESR, ↑ CRP, mild leukocytosis. ↑ Troponin I/T suggests perimyocarditis.
Imaging:
- CXR: Usually normal. “Water-bottle heart” if large effusion (>200mL) present.
- Echocardiogram: Initial test to rule out effusion or tamponade; often normal in uncomplicated pericarditis.

Imaging
- CT and cardiac MRI
  - Pericardial thickening > 2 mm
  - Calcifications

First-line (Idiopathic/Viral): NSAIDs (Ibuprofen or Indomethacin) + Colchicine (colchicine significantly ↓ recurrence rate).
Second-line / Refractory: Corticosteroids (Prednisone). Note: Avoid steroids as first-line unless NSAIDs are contraindicated (e.g., pregnancy, severe renal disease) or if etiology is autoimmune, due to high risk of recurrence.
Etiology-Specific Variants:
- Post-MI: Aspirin + Colchicine (Avoid other NSAIDs & steroids; they impair myocardial scar formation and ↑ risk of ventricular free wall rupture).
- Uremic Pericarditis: Hemodialysis (NSAIDs/colchicine are ineffective and contraindicated).