What is pericarditis?

Pericarditis is inflammation of the pericardium — the two-layer fibrous sac that surrounds and protects the heart. The outer parietal layer and inner visceral layer (the epicardium) become inflamed, causing: sharp, stabbing chest pain that worsens with breathing (pleuritic) and lying flat, and improves by sitting forward; a friction rub (scratching sound on auscultation, pathognomonic when heard); characteristic saddle-shaped ST elevation with PR depression on ECG; sometimes a pericardial effusion (fluid between the layers). In high-income countries, most pericarditis (approximately 70-90%) is viral or idiopathic — occurring after an upper respiratory tract infection. In low-income countries, tuberculosis is the most common cause.

How is pericarditis treated?

For viral/idiopathic pericarditis: NSAIDs (ibuprofen 600mg TDS; aspirin 750-1000mg TDS; indomethacin — for 2-4 weeks until symptoms and CRP normalise); PLUS colchicine 0.5mg twice daily for 3 months (or 0.5mg once daily if <70kg) — the key addition that halves recurrence rates (ICAP trial 2013). Restrict strenuous physical activity until symptoms resolve and CRP normalises (athletes should extend restriction for 3 months with normal echo and ECG). Avoid corticosteroids for idiopathic/viral pericarditis — associated with higher recurrence. Specific treatments for identified causes: anti-TB drugs for TB pericarditis; treat underlying CTD for autoimmune pericarditis.

What is cardiac tamponade?

Cardiac tamponade is a medical emergency — pericardial effusion accumulates faster than the pericardium can stretch, raising intrapericardial pressure until it equals cardiac filling pressure → cardiac chambers cannot fill in diastole → cardiac output falls dramatically. Clinical signs: Beck's triad (hypotension, raised JVP, muffled heart sounds); pulsus paradoxus (>10 mmHg systolic BP fall on inspiration — palpable as weakening of the radial pulse); tachycardia; rapid deterioration. Echocardiography: circumferential effusion + RV collapse in diastole (pathognomonic); respiratory variation in tricuspid/mitral inflow. Treatment: immediate pericardiocentesis (needle drainage under ultrasound guidance) — life-saving. Rarely, surgical drainage is required.

What causes recurrent pericarditis?

Recurrent pericarditis (occurring in approximately 20-30% of first-attack patients) has multiple mechanisms: Incomplete treatment: not completing the full NSAIDs + colchicine course. Autoinflammatory pericarditis: some patients have overactivation of the IL-1 inflammasome (similar to Still's disease and familial Mediterranean fever) → recurrent pericardial inflammation independent of any ongoing infection. DIRA (deficiency of IL-1 receptor antagonist) is an extreme form. Evidence: colchicine (which inhibits the NLRP3 inflammasome) prevents recurrences; IL-1 blockade (anakinra, rilonacept) is highly effective in recurrent cases. Corticosteroid use during first attack: predisposes to recurrence by facilitating viral replication and suppressing the immune clearance needed for resolution.

What is rilonacept and when is it used?

Rilonacept (Arcalyst, Kiniksa Pharmaceuticals) is an IL-1α and IL-1β receptor antagonist (a fusion protein that traps both IL-1 cytokines) — FDA-approved in March 2021 for the treatment of recurrent pericarditis. The RHAPSODY trial (NEJM 2021): 86 patients with colchicine-resistant recurrent pericarditis; rilonacept SC weekly injection vs placebo; 91% reduction in recurrence risk at 16 weeks; time to first recurrence event HR 0.04 (p<0.001). After rilonacept withdrawal, pericarditis recurred in placebo arm but not rilonacept arm — suggesting modification of the autoinflammatory process. Expensive; appropriate for patients with ≥2 recurrences resistant to colchicine. Alternative IL-1 blocker: anakinra (off-label, excellent evidence, much cheaper).

How does GMJ News cover pericarditis?

GMJ News covers ESC pericarditis guidelines, colchicine COPE/ICAP trial evidence, rilonacept 2021 FDA approval, cardiac tamponade emergency (Beck's triad, pericardiocentesis), the corticosteroid-recurrence paradox, constrictive pericarditis, TB pericarditis (LMIC context), pulsus paradoxus, friction rub, and saddle-shaped ST elevation ECG. Pericarditis is directly relevant to PHIG's cardiology and emergency medicine programmes, particularly the TB pericarditis burden relevant to Georgia's epidemiological context.

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Pericarditis

Q: What is cardiac tamponade?

Cardiac tamponade is a medical emergency — pericardial effusion accumulates faster than the pericardium can stretch, raising intrapericardial pressure until it equals cardiac filling pressure → cardiac chambers cannot fill in diastole → cardiac output falls dramatically. Clinical signs: Beck's triad (hypotension, raised JVP, muffled heart sounds); pulsus paradoxus (>10 mmHg systolic BP fall on inspiration — palpable as weakening of the radial pulse); tachycardia; rapid deterioration. Echocardiography: circumferential effusion + RV collapse in diastole (pathognomonic); respiratory variation in tricuspid/mitral inflow. Treatment: immediate pericardiocentesis (needle drainage under ultrasound guidance) — life-saving. Rarely, surgical drainage is required.

Q: How does GMJ News cover pericarditis?

GMJ News covers ESC pericarditis guidelines, colchicine COPE/ICAP trial evidence, rilonacept 2021 FDA approval, cardiac tamponade emergency (Beck's triad, pericardiocentesis), the corticosteroid-recurrence paradox, constrictive pericarditis, TB pericarditis (LMIC context), pulsus paradoxus, friction rub, and saddle-shaped ST elevation ECG. Pericarditis is directly relevant to PHIG's cardiology and emergency medicine programmes, particularly the TB pericarditis burden relevant to Georgia's epidemiological context.

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Pericarditis — inflammation of the pericardium (the fibrous two-layer sac surrounding the heart) causing the characteristic sharp pleuritic chest pain relieved by leaning forward — is the most common pericardial disease, predominantly viral or idiopathic in high-income countries (approximately 70-90% of cases), and is now managed by the transformative evidence that colchicine halves recurrence rates when added to NSAIDs (COPE 2005, ICAP 2013 trials) — a finding that changed ESC guidelines worldwide — while the most dangerous complication, cardiac tamponade (Beck’s triad: hypotension + elevated JVP + muffled heart sounds), requires emergency pericardiocentesis (WHO). Rilonacept (Arcalyst) — an IL-1 receptor antagonist — received FDA approval in March 2021 as the first treatment specifically indicated for recurrent pericarditis, achieving 91% reduction in recurrence in the RHAPSODY trial and transforming management for the most refractory cases.

Key messages

Colchicine halves recurrence — the defining trial evidence

The COPE (2005) and ICAP (2013) trials both demonstrated that colchicine added to NSAIDs halves pericarditis recurrence rates: ICAP: colchicine 0.5mg BD × 3 months after first attack → 18.4% vs 36.7% recurrence at 18 months. ESC 2015 guidelines: colchicine is a Class I recommendation for all first-attack and recurrent pericarditis. Colchicine is the defining pharmacological advance in pericarditis management.

Cardiac tamponade — Beck's triad emergency

Cardiac tamponade: pericardial fluid accumulates under pressure → compresses the heart → reduces cardiac output. Beck's triad: (1) hypotension; (2) elevated JVP (distended neck veins); (3) muffled heart sounds. Additional signs: pulsus paradoxus (>10 mmHg inspiratory fall in systolic BP); tachycardia; Kussmaul's sign (JVP rises on inspiration). Treatment: immediate pericardiocentesis (or surgical drainage). Echo first if time permits — shows circumferential effusion with RV collapse in diastole (pathognomonic).

Leaning forward relieves the pain — the pathognomonic posture

Pericarditis chest pain is classically: sharp; pleuritic (worse on deep inspiration); worse when lying flat; relieved by sitting forward and leaning on the knees. The mechanism: sitting forward shifts the heart away from the inflamed parietal pericardium. This position is so characteristic that it can help clinically distinguish pericarditis from ACS (where the patient is typically writhing, rolling around in distress without positional relief).

Rilonacept — first approved treatment for recurrent pericarditis (FDA 2021)

Rilonacept (Arcalyst, IL-1α/β receptor antagonist) — FDA approved March 2021 for recurrent pericarditis. RHAPSODY trial (NEJM 2021): rilonacept vs placebo; 91% reduction in recurrence risk; time to recurrence event HR 0.04 (p<0.001). Transforms management of the most refractory recurrent cases that fail colchicine. Subcutaneous weekly injection; expensive; most appropriate after ≥2 colchicine-resistant recurrences.

Corticosteroids increase recurrence — use only when necessary

Counterintuitively, corticosteroids are associated with higher pericarditis recurrence rates when used empirically in idiopathic/viral pericarditis. Mechanism: corticosteroids may facilitate viral replication; they suppress the inflammation needed to clear the causative trigger. ESC guidelines: avoid corticosteroids in idiopathic/viral pericarditis unless NSAIDs/colchicine fail, or for specific indications (connective tissue disease, autoinflammatory, uremic, pregnancy).

TB pericarditis — the world's most common cause

Globally, Mycobacterium tuberculosis is the most common cause of pericarditis. TB pericarditis causes: large effusions (often haemorrhagic); high risk of constrictive pericarditis (25-50% of survivors develop constrictive pericarditis — from pericardial fibrosis and calcification); high morbidity and mortality. Treatment: anti-TB drugs (standard 6-month regimen) + corticosteroids (prednisolone — reduces constriction risk). Diagnosis: pericardial fluid (AFB culture, adenosine deaminase — ADA >40 IU/L highly suggestive); pericardial biopsy.

Key statistics

50%

reduction in pericarditis recurrence with colchicine (ICAP 2013 trial)

NEJM 2013

March 2021

rilonacept (Arcalyst) FDA approval for recurrent pericarditis

FDA 2021

91%

reduction in recurrence risk with rilonacept vs placebo (RHAPSODY)

NEJM 2021

Beck's triad

hypotension + elevated JVP + muffled sounds — tamponade clinical diagnosis

Clinical

most common pericarditis cause globally; 25-50% risk of constrictive pericarditis

WHO/ESC

Class I

colchicine ESC guideline recommendation for all acute and recurrent pericarditis

ESC 2015

Pericarditis aetiology by region — viral/idiopathic (HICs) vs TB (LMICs)

Source: ESC/WHO. Aetiology differs dramatically by region — TB pericarditis dominates in sub-Saharan Africa.

Glossary of key terms

Friction rub
Clinical/AuscultationA pathognomonic (when present) auscultatory finding of pericarditis: a scratching, grating, high-pitched sound heard best with the diaphragm of the stethoscope, at the left sternal border, in expiration with the patient leaning forward. May have 2 or 3 components (corresponding to atrial systole, ventricular systole, ventricular diastole). Described as "walking on fresh snow." Transient and evanescent — may not be heard on a single examination. Absence of friction rub does not exclude pericarditis.

Saddle-shaped ST elevation
ECG/CardiologyThe characteristic ECG pattern of acute pericarditis — distinguished from the convex ST elevation of ST-elevation MI: Pericarditis: diffuse ST elevation in multiple leads (not just one coronary territory); saddle-shaped (concave up) ST elevation; PR segment depression (often the most specific feature — depression of the PR segment in limb leads, particularly II); no reciprocal ST depression (except in aVR and V1). STEMI: convex ST elevation localised to one coronary territory; reciprocal ST depression in opposite leads; Q waves may develop; hyperacute T waves.

Constrictive pericarditis
ESC/CardiologyChronic fibrotic thickening of the pericardium restricting diastolic filling of all cardiac chambers — most commonly following: TB pericarditis (highest risk); recurrent viral/idiopathic pericarditis (after multiple attacks); post-cardiac surgery or radiation. Clinical features: signs of right heart failure (elevated JVP with Kussmaul's sign — JVP rises with inspiration, opposite of normal); pericardial knock (high-pitched early diastolic sound); ascites; peripheral oedema. CT/CMR: pericardial thickening (>4mm) and calcification. Treatment: pericardiectomy (surgical stripping of the pericardium) — only cure; high perioperative mortality.

Pulsus paradoxus
Clinical/PhysiologyAn exaggerated (>10 mmHg) drop in systolic blood pressure during inspiration — palpable at the radial pulse as a decrease or disappearance of the pulse on inspiration. Normal physiology: systolic BP falls <10 mmHg with inspiration due to increased venous return to the right heart temporarily reducing LV filling. In tamponade: the tense pericardial effusion means any RV expansion (during inspiration) compresses the LV → exaggerated LV filling reduction → pulse diminishes or disappears with inspiration. Can be measured with a manual sphygmomanometer. Also present in severe asthma, COPD and significant pulmonary embolism.

Incessant and recurrent pericarditis
ESC 2015Incessant pericarditis: symptoms continue without remission for >4-6 weeks. Recurrent pericarditis: after a documented free interval of ≥4-6 weeks, symptoms recur; occurs in approximately 20-30% of patients after a first episode. Risk factors for recurrence: failure to respond to initial colchicine therapy; corticosteroid use during first attack; elevated CRP at symptom resolution. Management of recurrent: intensify colchicine (extend duration to 6-12 months); consider IL-1 blockade (anakinra — off-label with good evidence; rilonacept — FDA-approved). Pericardiectomy reserved for most refractory, symptomatic cases.

Myopericarditis
ESC/CardiologyInflammation involving both the myocardium and pericardium simultaneously — diagnosed when pericarditis criteria are met AND evidence of myocardial involvement (elevated troponin; new LV systolic dysfunction; CMR evidence of myocarditis). Typically caused by the same viral triggers as isolated pericarditis or myocarditis. Management: treat as pericarditis (NSAIDs + colchicine) + restrict physical activity for longer duration (3-6 months until biomarkers and LV function normalise). The pericarditis component generally heals; the myocarditis component may cause persistent LV dysfunction.

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