Evaluation and Management of Pericarditis

Massimo Imazio


Expert Rev Cardiovasc Ther. 2011;9(9):1221-1233. 

In This Article

Abstract and Introduction


Pericarditis may be caused by infectious or noninfectious noxa. Most cases are labeled as 'idiopathic' because the traditional diagnostic approach often fails to identify the etiology. Most important causes are presumed to be viruses in countries with a low prevalence of tuberculosis and tuberculosis in developing countries. Noninfectious pericarditis mainly includes autoimmune systemic diseases, post-pericardiotomy syndromes and neoplastic pericardial disease. Treatment should be targeted to the cause, but remains empirical with NSAIDs and the possible adjunct of colchicine in idiopathic cases. Corticosteroids use should be limited to patients with NSAID contraindications/intolerance or failure, and rarely for specific conditions (i.e., pregnancy and systemic autoimmune diseases). Recurrences are the most common complication, but the overall prognosis is related to the etiology, usually benign in idiopathic pericarditis.


The pericardium consists of a double-layered sac that provides mechanical protection, reduces the friction between the heart and surrounding structures, and limits the distension of the heart contributing to diastolic coupling of the ventricles (Figure 1). Normally, this function is achieved by the presence of a small amount of pericardial fluid (25–50 ml) produced by the visceral pericardium and intrapericardial pressure is equal to intrapleural pressure.[1–4] Pericarditis is the inflammation of the pericardial sac caused by infectious or noninfectious noxa with the possible increased production of pericardial fluid as exudate.[3,4]

Figure 1.

The pericardium consists of an outer sac (the fibrous pericardium) and an inner double-layered sac (the serous pericardium). The proximal portions of the great vessels (aorta and pulmonary artery) reside in the pericardial sac. AO: Aorta; LA: Left atrium; LV: Left ventricle; PA: Pulmonary artery; RA: Right atrium; RV: Right ventricle; SVC: Superior vena cava.

Pericarditis is responsible for approximately 5% of emergency department presentations of nonischemic chest pain.[3–5] Few epidemiological data are available; in a recent prospective study the incidence of acute pericarditis was 27.7 cases per 100,000 population/year in an urban area.[5] Pericarditis may recur in 10–30% of cases according to individual susceptibility and adopted drug treatments.[6]

Chronic inflammation with fibrosis, calcification and organization of pericardial fluid may lead to a rigid, usually thickened and calcified pericardium with a possible evolution towards pericardial constriction. In clinical practice, acute pericarditis is the term used for the index attack of pericarditis, while recurrent pericarditis describes subsequent episodes of the disease; chronic pericarditis refers to forms of pericarditis lasting for more than 3 months.

The only available international guidelines for the management of pericardial diseases were issued by European Society of Cardiology in 2004. At present, there are no available updates[7] and no specific guidelines have been issued on this topic by the American Heart Association and the American College of Cardiology.

This article will review contemporary knowledge on the etiology, clinical presentation, diagnosis, therapy and prevention of pericarditis based on original papers, clinical trials, meta-analyses and reviews published in the last 5 years.


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