Common Pericarditis Symptoms (and How Pericarditis Is Diagnosed)

Pericarditis is a relatively common disease, accounting for around 5% of all causes of chest pain seen in the emergency room. The cardinal symptom of pericarditis is a sudden, sharp pain in the middle or left side of the chest that worsens when taking a deep breath and eases when leaning forward.

Because the symptoms of pericarditis mimic those of a heart attack and other life-threatening conditions, call 911 and be assessed in an emergency room when experiencing chest pains.

Pericarditis is caused by swelling and irritation of the pericardium—a thin sac enclosing the heart muscle. In many individuals, the cause of pericarditis is unknown but presumed to be a viral infection. Other possible causes include autoimmune diseases, cancer, chest trauma, and kidney failure.

This article reviews the symptoms of pericarditis and possible complications, including recurrent episodes and what can happen if excess fluid builds up around the heart. It will also discuss how pericarditis is diagnosed and distinguished from more serious diagnoses like a heart attack. 

Chest Pain

More than 95% of people with acute pericarditis experience sharp retrosternal (behind the breastbone) chest pain that comes on suddenly and worsens when taking in a deep breath.

Also, the chest pain associated with acute pericarditis tends to feel worse when lying down and improves in the seated position or when leaning forward.

Other chest pain features seen in pericarditis include:

• Variable pain intensity—mild, moderate, or severe
• Pain that spreads to the neck, jaw, or upper arms
• Pain that worsens with coughing or swallowing food
• In some cases, the pain is described as dull and pressure-like, or even throbbing, in quality

Pericarditis is not generally considered a dangerous condition, and most people diagnosed with it recover well within a few weeks to months with prompt treatment and rest.

That said, its symptoms, namely chest pain, can mimic those seen with life-threatening conditions, such as:

• Myocardial infarction (heart attack)
• Pulmonary embolism (blood clot in the lung)
• Aortic dissection (a tear in the body's main artery)

As such, it's crucial to seek emergency medical attention if you or a loved one is experiencing chest pain.

Fever

Although less common than chest pain, fever is also a potential symptom of pericarditis. Fever develops when the temperature set point is altered in the hypothalamus, a gland deep within the brain.

Fever in pericarditis can be caused by an infection, cancer, or autoimmune diseases like lupus, rheumatoid arthritis (RA), or scleroderma.

Fever is also a symptom of pericarditis that develops after surgery on the heart that involves opening the pericardium—what's known as postpericardiotomy syndrome.

Unfortunately, in a person with pericarditis, a temperature greater than 100.4 degrees F indicates a poorer prognosis (outcome) and reason for hospital admission for treatment.

Weakness

Generalized weakness, malaise (feeling unwell), and fatigue are commonly seen in pericarditis.

Weakness in pericarditis may result from the inflamed pericardium itself, the underlying cause (e.g., a viral infection), or some combination.

Severe weakness and tiredness often develop if the pericarditis persists (e.g., chronic pericarditis) or impairs the heart's ability to pump blood—a complication called cardiac tamponade, discussed below.

Trouble Breathing

Trouble breathing, or dyspnea, is another possible symptom of pericarditis and may be accompanied by an increasing respiratory rate (tachypnea).

While dyspnea usually accompanies chest pain, research suggests that older females with pericarditis may experience problems breathing in the absence of chest discomfort.

As with weakness, cardiac tamponade can cause more severe breathing difficulties—termed respiratory distress.

Cough

A dry cough is another symptom of pericarditis, although it rarely occurs alone, without chest pain, fever, or trouble breathing.

A cough is a natural reflex that arises when sensory receptors throughout the airways are activated by triggers such as mucus, smoke, touch, or pressure. This causes the receptors to send signals to the brain stem via the vagus nerve.

Like the airways, the pericardium also contains receptors capable of stimulating cough when triggered by swelling, which occurs in pericarditis.

Heart Palpitations

Heart palpitations, the sensation of a fluttering, irregular, or pounding heartbeat, are also possible symptoms of pericarditis.

Palpitations can be accompanied by a fast heart rate (tachycardia), and they may suggest the presence of myocarditis, which can coexist with pericarditis—what's known as myopericarditis.

Myocarditis is inflammation of the heart muscle and causes similar symptoms as pericarditis, although a subset of affected individuals present with life-threatening heart arrhythmia and heart failure.

Other

Depending on the cause of the pericarditis, other symptoms may be present.

For example, a person with pericarditis from a viral infection may also experience muscle aches, sore throat, runny nose, or diarrhea.

When pericarditis is caused by an autoimmune disease, like lupus or RA, symptoms can include unintended weight loss, rash, or joint pain.

Weight loss may also occur with pericarditis related to cancer or a bacterial infection, especially tuberculosis.

Hiccups or trouble swallowing (dysphagia) have been reported in acute pericarditis. These symptoms are thought to arise from irritated or compressed structures located near a swollen, fluid-filled pericardium.

Possible Complications of Pericarditis

A rare but life-threatening complication of pericarditis is cardiac tamponade, which occurs when excess fluid buildup within the pericardium, called pericardial effusion, squeezes the heart muscle, preventing it from pumping blood effectively.

Three classic signs of cardiac tamponade are:

• Low blood pressure
• Muffled heart sounds
• Swollen neck veins

Cardiac tamponade requires immediate fluid drainage through a procedure called a pericardiocentesis.

Other complications of pericarditis are:

• Recurrent pericarditis: New symptoms of acute pericarditis develop after four to six weeks of no symptoms.
• Chronic pericarditis: Symptoms of pericarditis last more than three months.
• Constrictive pericarditis: A chronically swollen and irritated pericardium starts to scar and thicken, impacting the heart's function.

Symptoms of Chronic Pericarditis

An estimated 15% to 30% of individuals with acute pericarditis will experience recurrent or chronic pericarditis.

With recurrent pericarditis, symptoms resemble those of acute pericarditis but tend to be less severe.

Symptoms of chronic pericarditis include tiredness, coughing, and shortness of breath. Chest pain may or may not be present.

Key symptoms and signs of constrictive pericarditis—a severe form of chronic pericarditis—include:

• Swelling (edema), especially in the ankles and legs
• Fluid accumulation in the belly (ascites)
• Loss of appetite
• Fatigue
• Trouble breathing
• Light-headedness from low blood pressure (hypotension)

How Pericarditis Is Diagnosed

When diagnosing pericarditis, a healthcare provider will consider a person's symptoms, physical exam findings, and results from various diagnostic tests.

Medical History

During a medical history, in addition to inquiring about symptoms, including the duration, severity, quality, and location of the chest pain, a healthcare provider will ask about medication use and history of health conditions, such as a recent viral infection.

Physical Exam

Next, they will perform a physical examination, starting with taking vital signs (temperature, heart rate, blood pressure, breathing rate) and listening to their heartbeat with a stethoscope.

The presence of a pericardial friction rub on the heart exam is a highly specific finding for pericarditis.

Diagnostic Tests

After a physical exam, a person will undergo an electrocardiogram (ECG). The ECG measures the heart's electrical activity and is crucial for ruling out potentially life-threatening conditions that mimic pericarditis, like a heart attack.

An ECG classically shows widespread concave "saddle-shaped" ST elevation in acute pericarditis. The ST segment represents the time between when the heart's ventricles contract and recover.

Additional diagnostic tests for pericarditis include:

• A chest X-ray may reveal a "boot-shaped" heart if a pericardial effusion is present.
• An echocardiogram uses sound waves to create pictures of the heart. It can reveal the presence of a pericardial effusion and/or cardiac tamponade.
• Elevated inflammatory blood markers—C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR or sed rate)—support a diagnosis of acute pericarditis.

Sometimes, cardiac computed tomography (CT) or cardiac magnetic resonance (CMR) imaging may be ordered, mainly if other tests are inconclusive or symptoms are atypical. They can support a diagnosis of pericarditis, including constrictive pericarditis.

When to Contact a Healthcare Provider

If you are experiencing any chest pain, call 911 right away, as the pain may be a sign of a heart attack.

Also, contact your healthcare provider if you are being treated for pericarditis and your symptoms are worsening or persisting or you develop new symptoms like swelling, trouble breathing, or heart palpitations. 

Summary

Pericarditis is inflammation of the pericardium, the protective tissue that encloses the heart muscle. The primary symptom of pericarditis is a sudden, sharp pain in the middle or left side of the chest. This pain worsens when taking a deep breath and lessens when leaning forward.

Other common symptoms are fever, generalized weakness, trouble breathing, abnormal heart sensations (palpitations), and cough.

The most severe complication of acute pericarditis is cardiac tamponade—a medical emergency that arises when extra fluid inside the pericardium squeezes the heart muscle, impairing its function. Additional complications include recurrent episodes of pericarditis or, rarely, scar tissue formation within the pericardium (constrictive pericarditis).

With proper treatment and rest, most people with acute pericarditis recover well without complications. However, since symptoms of pericarditis resemble those of a heart attack, emergency medical attention is warranted to sort out the correct diagnosis.