Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Pericarditis

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In one line

·The sac around the heart is swollen and irritated.

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Normal physiology

·The pericardium is a smooth, two-layer sac that wraps snugly around the heart, with a tiny amount of slippery fluid between the layers so the heart can beat and twist without grinding against anything.

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What goes wrong

·The pericardium gets inflamed and swollen, usually because a virus, the immune system, or another trigger irritates it; the two layers start rubbing and leaking fluid instead of gliding smoothly.

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Hallmark signs

·Sharp chest pain that gets worse when you lie flat and better when you sit up and lean forward
·Chest pain that gets sharper when you take a deep breath, cough, or swallow
·A scratchy, squeaky sound (friction rub) when the doctor listens to your heart
·Low-grade fever (usually under 100.4°F or 38°C)
·Diffuse ST-segment elevation (the line after each heartbeat rises) on the EKG in almost all the heart's electrical zones, plus the PR segment dips down
·Feeling tired and achy, like you have the flu
·Beck triad: low blood pressure, bulging neck veins, and muffled (quiet) heart sounds
·Pulsus paradoxus: your blood pressure drops more than 10 mmHg when you breathe in

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Red flags · escalate now

·Fever above 100.4°F (38°C), especially if it won't come down — suggests infection inside the pericardium
·Large pericardial a fluid collection (effusion) (more than 20 mm of fluid around the heart on ultrasound) — risk of tamponade
·Cardiac tamponade (the heart squeezed by fluid around it) signs: low blood pressure, bulging neck veins, muffled heart sounds, or pulsus paradoxus — the heart is being squeezed and can't pump
·Chest pain that does not improve when sitting forward, or pain that feels crushing like a heart attack — may be myopericarditis (heart muscle is inflamed too) or a different emergency
·Not getting better after one week of anti-inflammatory medicine, or symptoms come roaring back — suggests a tougher cause like tuberculosis, cancer, or autoimmune disease

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Workup

·Electrocardiogram (ECG)
·Troponin blood test
·C-reactive protein (CRP) and red blood cell (erythrocyte) sedimentation rate (ESR)
·Transthoracic echocardiogram (ultrasound of the heart)
·Complete blood count (CBC)
·Blood urea nitrogen (BUN) and creatinine
·Chest X-ray
·Tuberculosis testing (interferon-gamma release assay or tuberculin skin test) and pericardial fluid analysis if a fluid collection (effusion) is drained

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Treatment

·Nonsteroidal anti-inflammatory drug (NSAID) — ibuprofen 600–800 mg three times daily, aspirin 750–1000 mg three times daily, or indomethacin 25–50 mg three times daily for 1–2 weeks, then taper over 2–4 weeks
·Colchicine 0.5 mg once daily (if weight < 70 kg) or twice daily (if weight ≥ 70 kg) for 3 months
·Treat the upstream cause — dialysis for kidney failure, antibiotics (e.g. anti-tuberculosis therapy: isoniazid, rifampin, pyrazinamide, ethambutol) for bacterial or TB pericarditis, chemotherapy or radiation for cancer, steroids or disease-modifying drugs for autoimmune pericarditis
·Pericardiocentesis — needle drainage of fluid from the pericardial sac — if signs of tamponade appear (low blood pressure, bulging neck veins, muffled heart sounds, pulsus paradoxus) or if a very large a fluid collection (effusion) is causing symptoms
·Avoid corticosteroids (e.g. prednisone) as first-line therapy; reserve steroids for recurrent pericarditis that fails NSAIDs and colchicine, or for autoimmune or uremic pericarditis
·Restrict strenuous activity — no competitive sports, heavy lifting, or intense exercise until symptoms resolve and inflammatory markers (CRP, ESR) return to normal (usually 3 months)
·Gastroprotection with a proton pump inhibitor (e.g. omeprazole 20 mg daily) if the patient is taking NSAIDs and has a history of stomach ulcers or is at high risk for bleeding

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NCLEX trap

·In pericarditis, the ST goes up across many leads (many spots on the tracing) and the PR segment drops, which is called PR depression. In a heart attack, the ST only goes up where one blocked artery feeds, and troponin (a protein that leaks from dying heart muscle) climbs high. The tracing pattern and the story (pain that shifts when you move or breathe, friction rub sound, no tender spots on the chest wall) tell them apart.
·Steroids actually make pericarditis come back more often. Start with nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or indomethacin for one to two weeks, then add colchicine for three months. Save steroids for cases caused by the immune system attacking itself, or when NSAIDs do not work.
·Pericarditis with fluid can get worse quietly. Watch for muffled heart sounds, neck veins that stand out high, and pulsus paradoxus (blood pressure drops more than ten when you breathe in) even if pain is mild. Tamponade is the thing that can kill, not the pain.
·Only drain if tamponade is happening (blood pressure falling, heart cannot fill), if the fluid pocket is huge and causing symptoms, or if you think infection is inside. Many fluid pockets in pericarditis shrink on their own with NSAIDs and colchicine.
·Always ask: is this from a virus, unknown cause, the immune system, kidney failure, a recent heart attack (Dressler syndrome), heart surgery, cancer, bacteria, or tuberculosis? Treat the cause, not just the swelling. A patient on dialysis needs fluid pulled off; a patient with TB needs antibiotics that kill TB.
·Pericarditis needs weeks to months of rest to let the sac around the heart heal and stop the swelling from bouncing back. Going back to exercise too soon raises the chance it will come back.

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