Pericarditis

ECG Findings

• Classic changes

  • Diffuse concave ST elevation in multiple leads

  • PR depression in most leads

  • PR elevation and ST depression in aVR

• Differentiation from STEMI

  • Pericarditis tends to cause widespread ST changes not confined to a single coronary territory

  • ST morphology is typically concave (smiling), rather than convex

Causes

• Idiopathic (most common)

• Viral infections (Coxsackie B, influenza)

• Autoimmune conditions (SLE, RA, scleroderma)

• Renal failure (uraemia)

• Post-cardiac injury syndromes (Dressler’s, post-surgical)

• Malignancy (direct invasion or metastatic to pericardium)

• TB (more common in immunosuppressed or endemic regions)

Diagnosis

• Clinical diagnosis requires ≥2 of the following 4 criteria

  • Characteristic chest pain: Sharp, pleuritic, improves on sitting forward

  • Pericardial friction rub on auscultation

  • ECG changes (diffuse concave ST elevation ± PR depression)

  • Pericardial effusion on echocardiography

• Supporting tests

  • Raised inflammatory markers (CRP, ESR)

  • Mild troponin elevation in myopericarditis

  • Echocardiography to detect effusion, check for tamponade physiology (right ventricular or atrial collapse), and assess any underlying structural heart disease

Treatment

• Hospitalisation Criteria

  • Temperature >38°C

  • Subacute or protracted course

  • No improvement with standard therapy (colchicine/NSAIDs)

  • Presence of pericardial effusion or any suggestion of tamponade (hypotension, elevated JVP, pulsus paradoxus)

  • Suspected bacterial or malignant pericarditis

• Outpatient Management for Stable Cases

  • Restrict strenuous activity until symptom-free to prevent recurrence

  • Colchicine

    • 500 micrograms BD if >70 kg

    • 500 micrograms OD if <70 kg

    • Continue for 3 months to reduce recurrence

  • NSAIDs (e.g. Ibuprofen 600 mg TDS for 1–2 weeks, then taper)

    • Alternatively, aspirin 750–1000 mg TDS for 1–2 weeks if post-MI or other NSAIDs contraindicated

    • Taper gradually to avoid rebound inflammation

  • Adjunctive Therapy

    • Consider acid suppression (PPI) with NSAIDs

    • Corticosteroids reserved for refractory cases or specific aetiologies (autoimmune) as they can increase relapse risk if stopped abruptly

Notes:

• Dressler’s syndrome (post-MI pericarditis) is usually managed with high-dose aspirin rather than other NSAIDs

• Large effusions can cause electrical alternans on ECG and raise concern for tamponade

• TB pericarditis may require prolonged anti-TB therapy and close monitoring for constriction

• Monitor for signs of constrictive pericarditis in chronic or recurrent cases (raised JVP, Kussmaul’s sign, diastolic knock on auscultation)

• Follow-up is essential to ensure resolution of inflammation, especially if high-risk features or recurrent episodes are present

Treatment of pericarditis