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Acute pericarditis
Pericarditis is diagnosed with two of four — pleuritic pain relieved by sitting forward, a pericardial rub, widespread ST elevation with PR depression, and a pericardial effusion — and treated with an NSAID together with colchicine for three months.
Why it matters in the exam
Questions ask you to separate pericarditis from STEMI on the ECG: in pericarditis the elevation is widespread and concave, without reciprocal change (except aVR and V1), and with PR depression; in STEMI the elevation is confined to one artery's territory with reciprocal change. The treatment (high-dose ibuprofen or aspirin with colchicine), the need to limit exercise until symptoms resolve and CRP normalises, and why steroids are second line — they raise the risk of recurrence — are also asked.
Other subjects: when to admit (fever above 38, subacute onset, a large effusion or tamponade, no response to an NSAID after a week, myocardial involvement, immunosuppression, trauma, anticoagulation), the causes — viral or idiopathic in most cases, tuberculosis in endemic areas, uraemia (which needs dialysis), after infarction and after cardiac surgery — and constrictive pericarditis: Kussmaul's sign, a pericardial knock, pericardial calcification, and treatment by pericardiectomy.
Another point that is asked is treatment after a myocardial infarction: there aspirin is chosen rather than another NSAID. In recurrent pericarditis colchicine is extended to six months, and in resistant cases anti-IL-1 biological treatment is considered.
Key points
- Diagnosis: 2 of 4 — typical pain, rub, widespread ST with PR depression, effusion.
- Treatment: high-dose NSAID or aspirin with colchicine for three months.
- Steroids only as second line — they increase recurrences.
- Admit with fever above 38, a large effusion, tamponade, myocardial involvement or anticoagulation.
- Constrictive pericarditis: Kussmaul's sign, knock, calcification; treated by pericardiectomy.
Summary table
| Item | The rule | Details | Trap |
|---|---|---|---|
| Diagnosis | 2 of 4: typical pain, rub, ECG changes, effusion | Widespread concave ST elevation, PR depression | CRP and troponin; echo for every patient |
| First treatment | NSAID with colchicine | Ibuprofen 600 mg three times daily or aspirin 750–1,000 mg three times daily, 1–2 weeks with tapering | Colchicine 0.5 mg twice daily (once daily below 70 kg) for 3 months |
| Steroids | Second line: NSAID contraindicated or autoimmune disease | Low dose with slow tapering | Increase the risk of recurrence |
| Admission | Fever above 38, large effusion, tamponade, myocardial involvement, anticoagulants, no response in a week | Search for a specific cause | Most patients are treated as outpatients |
| Constrictive pericarditis | Kussmaul's sign, pericardial knock, oedema and ascites | Calcification on CT, equalised diastolic pressures | Pericardiectomy |
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Sources
- ESC Guidelines for the management of myocarditis and pericarditis, 2025 — Acute and recurrent pericarditis
- ESC Guidelines for the diagnosis and management of pericardial diseases, 2015 — Acute pericarditis, constrictive pericarditis
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Pericardial Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.