MioAtlas
G6: Pericardium

Acute pericarditis

Acute inflammation of the pericardial sac (duration typically < 4–6 weeks) of infectious (frequently viral or idiopathic), autoimmune, post-pericardiotomy, or uremic etiology.

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Definition

Acute inflammation of the pericardial sac (duration typically < 4–6 weeks) of infectious (frequently viral or idiopathic), autoimmune, post-pericardiotomy, or uremic etiology. Clinically characterized by pleuritic chest pain that intensifies in the supine position and improves when leaning forward, auscultatory pericardial friction rub, dynamic ST and PR segment changes on the ECG, and facultative presence of typically small pericardial effusion [C2] [G6-12]. As Ariyarajah and Spodick point out in their review, «Acute pericarditis (AP) is basically a clinical diagnosis» [G6-12].

Severity criteria

  • Single grade: Established clinical diagnosis by the presence of at least ≥ 2 of the 4 classic diagnostic criteria:
    • Typical pericardial chest pain (retrosternal/precordial, sharp/pleuritic, aggravated by inspiration and supine position, relieved by sitting upright and leaning forward) [C2].
    • Auscultatory pericardial friction rub [C2] [G6-11].
    • Typical stage 1 electrocardiographic changes with diffuse concave ST elevation and PR segment depression [C2] [G6-12].
    • New or worsening pericardial effusion on echocardiography, typically mild with end-diastolic separation < 10 mm and estimated volume < 100 mL [C2] [G6-01].
  • High-risk clinical indicators: Fever > 38.0 °C, subacute course without response after 7 days of anti-inflammatory treatment with NSAIDs and colchicine, marked troponin elevation (myopericarditis), or moderate-to-large effusion [C2].

Findings by layer

Hemodynamics

  • Intracavitary pressures and hemodynamic parameters normal in the absence of effusion under tension [C2] [M5]:
    • Mean right atrial pressure: 2–6 mmHg (normal) [C2] [M5].
    • Systolic and diastolic blood pressure: Physiological normotension (systolic blood pressure 110–130 mmHg, diastolic blood pressure 70–85 mmHg) [C2].
    • Cardiac output: Normal (4.5–6.5 L/min) [C2].
    • LV ejection fraction (left ventricular ejection fraction): Preserved (≥ 55–65%) [C2].
    • Pulmonary capillary wedge pressure: Normal (6–12 mmHg) [C2].

Rhythm

  • Sinus tachycardia (sinus tachycardia, heart rate typically 100–115 bpm) reactive to chest pain and inflammation, or normal sinus rhythm [C2] [G6-12].

ECG

  • Spodick stage 1:
    • Diffuse upwardly concave ST-segment elevation (diffuse ST-segment elevation) in almost all leads (I, II, III, aVF, V2–V6), with the exception of aVR and V1 [C2] [G6-12].
    • Generalized PR-segment depression in leads with positive P waves and reciprocal elevation in aVR [G6-12].
    • Absence of pathological necrosis Q waves [C2] [G6-12].

Heart sounds and murmurs

  • Pericardial friction rub: Pathognomonic superficial, scratching, grating auscultatory finding [C2] [G6-11].
  • In Spodick's prospective study of 100 patients [G6-11], the predominance of three-component rubs was demonstrated: «triphasic pericardial rubs (56 percent of patients with sinus rhythm)» [G6-11]. When the rub is not triphasic, it may present in two components or a single one: «Fourteen of 15 monophasic rubs were audible or recordable only during ventricular systole» [G6-11].
  • Regarding auscultatory location and dynamics, «Rubs were best heard along the left sternal border in 84 percent of cases and tended to be louder during inspiration than during expiration» [G6-11].
  • Normal S1 and S2 heart sounds; absent murmurs [C2].

Arterial pulse

  • Normal peripheral arterial pulse [B4].
  • Preserved physiological respiratory variation, given that «Systolic blood pressure normally falls during quiet inspiration in normal individuals» [B5], with pulsus paradoxus absent (< 10 mmHg) [B5] [C2].

Jugular venous pulse

  • Normal jugular venous pressure (mean venous pressure in cmH₂O 5–8 cmH₂O) with physiological waves and troughs [B3].
  • Negative Kussmaul sign [B3] [C2].

Maneuvers

  • Leaning chest forward and held end-expiration: Increases audible rub intensity by bringing the heart closer to the anterior chest wall [C2] [G6-11].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Normal Sinus Rhythm

Also known as: Acute pericarditis · Acute pericardial inflammation · Fibrinous pericarditis · Acute idiopathic pericarditis · Pericarditis

Other pathologies in this group

Related clinical comparisons

Sources

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
  4. [C2] 2025 ESC Guidelines for the management of myocarditis and pericarditis . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf192 PubMed: 40878297
  5. [G6-01] American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography . J Am Soc Echocardiogr (2013) . DOI: 10.1016/j.echo.2013.06.023 PubMed: 23998693
  6. [G6-11] Pericardial rub. Prospective, Multiple observer investigation of pericardial friction in 100 patients . Am J Cardiol (1975) . DOI: 10.1016/0002-9149(75)90847-1 PubMed: 1114993
  7. [G6-12] Acute pericarditis: diagnostic cues and common electrocardiographic manifestations . Cardiol Rev (2007) . DOI: 10.1097/01.crd.0000233777.62568.b5 PubMed: 17172880
  8. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581