Dr Arvind Vasudeva

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What is pericarditis?

So, What is pericarditis?

Pericarditis is inflammation of the pericardium, the thin, fluid-filled sac that surrounds the heart. It is most often caused by viral infections, although it can also follow heart surgery, develop alongside autoimmune conditions, or occur after a heart attack. The condition typically causes sharp chest pain that worsens when lying flat and improves when sitting forward, and it is usually self-limiting with the right treatment.

Pericarditis is one of those conditions where patients arrive understandably worried, often because the chest pain feels alarming and they have read frightening things online. Over more than 20 years as a Consultant Cardiologist at Kingston Hospital, and across my private clinics at Parkside, The New Victoria, Cleveland Clinic London and Heartsure, I have assessed a great many patients with suspected pericarditis, and the reality is usually far more reassuring than the initial impression. Most cases settle within a few weeks, respond well to simple treatment, and do not cause lasting harm to the heart.

What causes pericarditis

Pericarditis develops when something irritates the pericardium, triggering inflammation. The causes I see most often in clinical practice are listed below.

  • Viral infections, including coronaviruses, enteroviruses, and influenza
  • Autoimmune conditions, such as lupus, rheumatoid arthritis and sarcoidosis
  • Following a heart attack, known as Dressler’s syndrome
  • After heart surgery or cardiac procedures
  • Kidney failure with high levels of urea in the blood
  • Cancer, in a small minority of cases
  • Bacterial or fungal infections, which are now rare in the UK
  • Idiopathic cases, where no clear cause can be found

Idiopathic pericarditis is far more common than many patients expect. Most of these cases are likely caused by a virus that was never identified at the time, often weeks before the chest pain began.

From the patients I’ve assessed over many years, taking a careful history of any recent infection or unusual illness works better than relying on extensive blood testing in the early stages, because the pattern of symptoms and their timing is often the strongest pointer to a viral cause.

The symptoms of pericarditis

The symptoms of pericarditis are usually quite distinctive once you know what to look for. The most common features I see in clinic are listed below.

  • Sharp, central chest pain, often worse when lying flat
  • Pain that eases when sitting up or leaning forward
  • Pain that worsens with deep breathing, coughing, or swallowing
  • A feeling of pain spreading to the left shoulder or neck
  • Mild fever, particularly in viral cases
  • Fatigue and a general feeling of being unwell
  • Breathlessness if fluid has built up around the heart
  • Palpitations in a smaller number of patients

The positional nature of the pain is the key feature. Patients often tell me they slept propped up because lying flat made the pain unbearable, and that piece of information alone is one of the clearest clues to the diagnosis.

What I’ve found across many years of assessing this kind of chest pain is that positional, breathing-related pain works better as an early indicator of pericarditis than ECG changes alone, because the pattern is so specific to the way the pericardium is irritated. The ECG can be subtle or even normal in early cases, but the history rarely is.

How pericarditis differs from a heart attack

This is one of the most common questions patients ask me when they arrive in clinic. The two conditions can both cause chest pain, but they tend to behave very differently.

The main differences I look for are listed below.

  • Pericarditis pain is sharp and positional, while heart attack pain is more often a pressure or tightness
  • Pericarditis pain is worse on breathing in, whereas heart attack pain is not
  • Pericarditis pain often improves on sitting forward, which is not the case in a heart attack
  • Heart attack pain is more likely to be brought on by exertion
  • ECG changes follow different patterns in the two conditions
  • Troponin blood tests can be raised in both, but more dramatically in a heart attack

That said, any new chest pain should be assessed properly. The two conditions can occasionally overlap, and pericarditis can sometimes occur alongside other cardiac problems.

How pericarditis is diagnosed

There is no single test that confirms pericarditis. The diagnosis comes from putting together the history, the examination, and the results of a few key investigations. The tests I typically arrange are listed below.

  • A 12-lead ECG, which often shows widespread ST elevation in a characteristic pattern
  • An echocardiogram, to check for fluid around the heart and to assess heart function
  • Blood tests, including troponin, inflammatory markers and full blood count
  • A chest X-ray, particularly if breathlessness or significant fluid is suspected
  • A cardiac MRI in selected cases, to confirm inflammation or rule out myocarditis
  • Further tests for autoimmune conditions, where the cause is unclear

Drawing on the imaging studies I’ve reviewed across many of these cases, an echocardiogram works better as a first-line test than a CT scan for most patients with suspected pericarditis, because it shows fluid around the heart immediately, is quick to arrange, and avoids radiation exposure. Cardiac MRI has a role in more complex cases, particularly where myocarditis is also a consideration.

Pericardial effusion, when fluid builds up

In some patients, the inflamed pericardium produces extra fluid, which collects between the two layers of the sac. This is known as a pericardial effusion. Most are small and cause no significant problem, but larger ones can affect the way the heart fills with blood.

The features I look for are listed below.

  • Increasing breathlessness on exertion or when lying flat
  • A drop in blood pressure
  • A faster than expected heart rate
  • Distended veins in the neck
  • Swollen ankles in more prolonged cases

The most serious form of fluid build-up is cardiac tamponade, where the pressure of the fluid prevents the heart from filling properly. This is uncommon but requires urgent treatment, usually by drainage of the fluid in hospital.

Treatment for pericarditis

The treatment of pericarditis depends on the cause and the severity, but the principles are well established. The approaches I use most commonly are listed below.

  • High-dose anti-inflammatory medication, usually ibuprofen or naproxen, for several weeks
  • Colchicine, an additional anti-inflammatory medication that significantly reduces the risk of recurrence
  • Stomach-protecting medication, to reduce the risk of side effects from the anti-inflammatories
  • Steroids, in selected cases where standard treatment has failed
  • Treatment of the underlying cause, where one is identified
  • Drainage of fluid, in cases of significant pericardial effusion
  • Avoidance of strenuous exercise until inflammation has fully settled

Looking across the patients I’ve treated for first-episode pericarditis, the combination of anti-inflammatories with colchicine works better than anti-inflammatories alone, because adding colchicine roughly halves the chance of the condition coming back. It also tends to shorten the duration of symptoms.

Pericarditis and exercise

This is an area where I am very clear with patients. Strenuous exercise while the pericardium is still inflamed can prolong symptoms and increase the risk of recurrence. The advice I give in clinic is generally as follows.

  • Avoid moderate-to-vigorous exercise until symptoms, ECG and inflammatory markers have normalised
  • Most patients can return to gentle activity within four to six weeks
  • Competitive athletes usually require a longer period of rest, often three months or more
  • Return to high-intensity sport should follow specialist review and, where appropriate, repeat imaging

From my work with patients who are keen runners, cyclists and gym-goers, taking a structured rest period works better than easing back in too early, because the patients who pause fully tend to recover more reliably and are less likely to develop recurrent pericarditis.

Recurrent pericarditis

Around one in four patients with pericarditis experiences at least one recurrence, often within the first 18 months. This is frustrating but usually manageable.

The points I focus on for these patients are listed below.

  • A longer course of colchicine, often six to twelve months
  • Careful tapering of anti-inflammatory medication, rather than stopping abruptly
  • Reassessment with imaging if symptoms return
  • Newer biological treatments in carefully selected cases that do not respond to standard therapy
  • A clear plan for what to do if symptoms recur

From the patients I have followed through recurrent episodes, a gradual reduction in anti-inflammatory medication works better than a quick stop, because the inflammation tends to flare again if the dose comes down too rapidly. Patience with the tapering schedule is often the key to staying well in the long term.

When to seek a cardiology opinion

It is worth seeking a specialist cardiac assessment if you have any of the following.

  • Sharp, positional chest pain, particularly after a recent viral illness
  • A previous diagnosis of pericarditis and a return of similar symptoms
  • A raised troponin or inflammatory marker on routine blood testing
  • Persistent breathlessness or fatigue following an infection
  • Concerns about your heart after COVID-19
  • A wish for clearance to return to sport after a previous episode

You can read verified feedback from patients I’ve seen if it helps you decide whether a private cardiology opinion is the right step for you.

Conclusion

Pericarditis is a condition that often sounds far more alarming than it is. While the chest pain can be sharp and frightening, the great majority of patients respond well to treatment, recover fully within weeks, and do not develop any lasting heart damage. The key is accurate diagnosis, a structured course of anti-inflammatory treatment, a sensible period of rest, and follow-up to make sure inflammation has fully settled.

If you have symptoms that may be due to pericarditis, or if you have had a previous episode and are concerned it may have returned, you can contact me, Dr Arvind Vasudeva, on 020 8977 4826 to arrange a structured cardiac assessment. I consult at Parkside Hospital in Wimbledon, The New Victoria Hospital in Kingston, Cleveland Clinic London and the Heartsure Clinic, and you can book a convenient appointment here through my secretary Hannah.