The Bottom Line:
At least 2 of the following 4 criteria should be present: (1) characteristic chest pain, (2) pericardial friction rub, (3) suggestive electrocardiographic (ECG) changes, and (4) new or worsening pericardial effusion (see Figure 1, p. 574).
In acute and relapsing pericarditis, history and findings on examination, ECG, and laboratory studies can be used to make a diagnosis. Additional imaging tools, including echocardiography, cardiac CT, and CMR, can be used when the diagnosis is equivocal or there is evidence of hemodynamic compromise. Management should be directed toward treating the underlying cause. Nonsteroidal anti-inflammatory drugs and colchicine are first-line treatment for idiopathic or viral acute or relapsing pericarditis, and corticosteroids should be limited to patients in whom NSAID and colchicine therapy has failed or is contraindicated or those whose relapsing pericarditis has an autoimmune or rheumatologic etiology.
In cardiac tamponade, echocardiography is the main diagnostic tool, and first-line treatment of unstable patients is urgent percutaneous catheter pericardiocentesis. The diagnosis of constrictive pericarditis and restrictive cardiomyopathy is challenging because of the considerable overlap in hemodynamic parameters. Increased ventricular dependence and discordant changes in LV and RV systolic pressure during respiration are features of pericardial constriction; in restrictive cardiomyopathy, these findings are not present, and LV and RV systolic pressures change concordantly during the respiratory cycle. Although constrictive pericarditis can be transient in a subset of patients and managed medically, most require surgical pericardiectomy, which can be performed with a very acceptable risk at experienced centers.