Clinical Presentation

History

The clinical presentation is usually one of acute onset of chest pain; classically this is pleuritic in nature and eased by sitting up and leaning forward. The pain may be anywhere over the anterior chest wall, but it is usually retrosternal. It may radiate to the arm like ischaemic pain. A characteristic feature of the pain which is specific for pericarditis is radiation to the trapezius ridge [3]; the phrenic nerve traverses the pericardium and also innervates this muscle.

Pain radiating to the trapezius ridge has high degree of specificity for pericarditis.

Examination

Pericardial friction rub has been reported in around a third of cases [9]. This rub is often dynamic so repeated examination may be useful if it is not heard at the outset. It is heard maximally during expiration and is loudest at the lower left sternal edge. It can be distinguished from a pleural rub by the fact that it will still be heard when the patient holds their breath.

A diagnosis of acute pericarditis should be made when at least 2 out of 4 of the following criteria are met [9]:

• Characteristic chest pain
• Pericardial friction rub
• Suggestive ECG changes
• New or worsening pericardial effusion

Additional supportive findings include

Raised markers of inflammation (CRP/ESR/WCC) and evidence of inflammation by imaging technique (CT/CMR)

Other clinical findings associated with the aetiology of the pericarditis:

Fever

A temperature over 38 degrees centigrade is a high risk feature for pericarditis. It may be associated with the presence of a bacterial infection (eg. a coexistent pneumonia).

Clinical features of HIV

HIV is associated with acute pericarditis in a number of ways. It can cause a direct infective pericarditis or pericarditis can be associated with other opportunistic infections such as CMV. Kaposi’s sarcoma and lymphoma can cause a non-infective pericarditis.

Clinical features associated with autoimmune disorders

Patients with the cutaneous or musculoskeletal features of rheumatoid arthritis, SLE and systemic sclerosis may be at risk of acute pericarditis relating to these diseases.

Patients presenting after a STEMI

This can occur early (within days) or late (months).

Clinical features of Uraemia

Patients with a raised urea may have non-specific features of nausea, vomiting, anorexia and itching. Pericarditis may occur in association with chronic or acute kidney injury.

Metastatic Disease

Metastatic lung and breast cancer are the commonest malignancies to cause acute pericarditis. The primary lung lesion may be seen on CXR

Other clinical findings associated with the complications of pericarditis

Cardiac Tamponade

The classic triad of distended neck veins, muffled heart sounds and hypotension (Beck’s triad) may not be present. Patients can have an insidious onset of tamponade and the symptoms and signs may be very non-specific. They may have orthopnoea, dysphagia, cough and occasionally episodes of loss of consciousness [9]. Echocardiography is required in all cases of suspected pericarditis in order to complete risk stratification.

Recurrent Pericarditis

Patients may give a history of previous resolved episodes of chest pain, or of ongoing chest pain which has required a prolonged course of NSAIDs.

Chronic Pericarditis

This is defined as pericarditis lasting for more than 3 months. Symptoms include chest pain, palpitations and fatigue.