History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include: male sex, age 20 to 50 years, transmural myocardial infarction, cardiac surgery, neoplasm, viral and bacterial infection, uraemia, dialysis treatment, and systemic autoimmune disorders.
The patient may present with a recent history of an upper respiratory tract infection or diarrhoeal illness.[15]
chest pain
This is the most common symptom and occurs in more than 85% of cases.[1]
Typically acute in onset, sharp, and pleuritic.[1] The pain may also be stabbing or aching.
Almost all patients report relief of pain with sitting up or leaning forward.[1]
Usually central but may radiate to one or both trapezius ridges (phrenic nerves both innervate the pericardium and trapezius ridges), the neck, the arms, or the left shoulder.[16]
Can mimic the pain of myocardial ischaemia or infarction (particularly when dull or pressure-like) or pulmonary embolism. See the Differentials section for more information
In practice, dull or pressure-like pain is commonly associated with myocardial involvement (myopericarditis or perimyocarditis).
Trapezius ridge pain is more specific for pericardial pain than pain due to myocardial infarction.[16]
Generally constant, not related to exertion, and poorly responsive to nitrates.[12][14]
Practical tip
It is crucial to rule out pulmonary embolism as a differential. If a patient with pericarditis is given anticoagulation (i.e., treatment-dose low molecular weight heparin), they can develop life-threatening cardiac tamponade due to bleeding into the pericardial space.[41]
Clinical features that distinguish pericarditis from pulmonary embolism (e.g., pericardial friction rub) may be transient or absent, so you should actively investigate and exclude pulmonary embolism in patients presenting with overlapping symptoms and signs.
See Pulmonary embolism.
Practical tip
Chest pain caused by myocardial ischaemia/infarction (rather than pericarditis) typically:
Is described as pressure-like, heavy, and squeezing, rather than sharp and pleuritic
Does not with vary with respiration or positional changes
Is not associated with a pericardial friction rub (unless there is associated pericarditis)[11][28][42]
Lasts minutes to hours, rather than hours to days
Is associated with other key features such as nausea and vomiting, marked sweating, or breathlessness (or particularly a combination of these), or risk factors for cardiovascular disease.[43]
pericardial rub
May be present in <33% of cases.[1]
It is a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border.[1] It is heard best at the left sternal edge and at the cardiac borders with the patient leaning forward at end-expiration.[11]
Often absent at initial presentation. Always examine a patient with suspected pericarditis repeatedly because the rub can come and go over several hours.[13] Sensitivity of a rub is based on the frequency of cardiac auscultation.
Practical tip
A pericardial friction rub can be distinguished from a pleural rub by asking a patient to hold their breath – a pericardial friction rub will still be heard when the patient holds their breath, and occurs with every heartbeat. A pericardial rub is heard maximally during expiration and can sound like the ‘crunch’ heard when walking over fresh snow.
Bear in mind that a pericardial rub may be absent if a large pericardial effusion is present because the inflamed pericardium will be separated and unable to rub together.
Other diagnostic factors
uncommon
fever
myalgias
A prodrome of myalgias and malaise may be present with any cause of acute pericarditis, particularly in young adults.
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