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An inflammatory syndrome is usually present with fever of >38°C (70%),37 elevated markers of inflammation (C-reactive protein) (80%– 90%),36,37 ESR, neutrophil leucocytosis,37,38 and pericardial and/or pleural effusion (approximately 50%), often with lung atelectasis, leading to a possible diagnosis of pleuro-pneumonia,37,103 and less commonly, peritoneal involvement (13%).38 This presentation is labelled ‘inflammatory phenotype’ of AP. Cardiac enzymes are usually normal, but troponin may be elevated in 20%–30% of cases, due to concomitant myocarditis (myopericarditis).4

4.4.2 Subacute pericarditis

Subacute pericarditis refers to cases with persistent symptoms lasting >1 month and <3 months. This condition may directly progress to constrictive pericarditis (CP) within a few months and requires timely optimal medical therapy and close follow-up to prevent chronic evolution.104

4.4.3 Chronic pericarditis

Chronic pericarditis refers to cases lasting >3 months. In pericarditis, management of the patient during the acute phase is of paramount importance, not only for symptom relief but, most importantly, for prognostic purposes. Hospitalization of patients with AP and high-risk features allows the prompt identification and treatment of potentially life-threatening complications, such as cardiac tamponade (CTP).105 Moreover, appropriate screening for specific aetiologies is the basis for tailored therapy. Progression of AP to subacute or chronic disease is sometimes unpredictable. Omission of colchicine administration and the use of high doses of corticosteroids with fast tapering are risk factors for recurrences or a chronic course of the disease.24,106–109 Recently, scores that predict the individual risk of complicated pericarditis and chronicity have been proposed for the identification of subjects who require intensive therapy in terms of medication dose and length, as well as close follow-up.43,44,110 They require further validation in prospective, multicentre studies. In chronic forms, symptoms are similar to previous attack(s), but often milder.1 In unclear cases or in difficult-to-treat patients, CMR may be performed to assess the degree of inflammation and individualize medical therapy, especially before drug tapering or discontinuation.111,112 Paradoxically, although chronic pericarditis significantly impairs quality of life, the rate of progression to CP is negligible (<1%) and is lower than the risk imposed by a single episode of AP, unless a specific aetiology is identified.105,113,114

4.5 Clinical presentations of pericarditis

Pericarditis is characterized by a wide spectrum of clinical presentations. The main presenting symptom of pericarditis is positional chest pain, which is reported in most affected individuals. Typical pericardial pain is sharp and is worse when coughing and taking a deep breath (pleuritic). Left trapezius ridge pain is a classic symptom of pericardial irritation and is transmitted through the phrenic nerve. Other less common symptoms include shortness of breath, fever, fatigue, and arrhythmia (e.g. AF). Pericardial effusion often accompanies pericarditis (>50% of cases). Other presentations include right HF-like symptoms [elevated jugular venous pressure (JVP), peripheral oedema, ascites] when constriction is present. Hypotension is a sign of CTP (which presents with Beck’s triad: hypotension, jugular venous distension, and muffled heart sounds). It is crucial to differentiate pericarditis from other diseases, such as ACS, congestive HF, pneumonia with pleuritis, pulmonary embolism, chronic obstructive pulmonary disease, and vasculitis.

4.5.1 Dry pericarditis

Dry pericarditis (40%–50% of cases), also referred to as ‘pericarditis sicca’, is a form of pericarditis that is characterized by inflammation of the pericardium without the presence of PEff. It can begin insidiously or abruptly. It is usually not associated with a specific cause or a worse prognosis.

4.5.2 Effusive pericarditis

Effusive pericarditis (50%–60% of cases) is characterized by the concurrent presence of effusion.115 A moderate to large PEff is more commonly associated with a non-idiopathic aetiology.

4.5.3 Effusive–constrictive pericarditis

Effusive–constrictive pericarditis (ECP) is characterized by the concurrent presence of PEff, along with thickening and constriction of the pericardium that restricts the normal filling of the heart.116 Effusive–constrictive pericarditis occurs when constrictive physiology is uncovered following the drainage of a PEff with tamponade. The exact haemodynamic definition involves the right atrial pressure (RAP) failing to fall by ≥50% or to a level of <10 mmHg despite intrapericardial pressure being lowered to near 0 mmHg with removal of pericardial fluid via pericardiocentesis.110,116,117 Current multimodality imaging allows a clinical diagnosis of ECP without cardiac catheterization.

4.5.4 Pericarditis with cardiac tamponade

The two most serious complications of pericarditis are CTP and CP. Pericarditis with CTP is a life-threatening condition where inflammation of the pericardium leads to the accumulation of compressive pericardial fluid (Table 8).110,115 Symptoms may include chest discomfort, fatigue, and dyspnoea. Clinical signs include hypotension, tachycardia, raised JVP, pulsus paradoxus, muffled heart sounds, electrical alternans with decreased ECG voltage, and an enlarged cardiac silhouette on chest X-ray. The magnitude of clinical and haemodynamic abnormalities depends on the amount of pericardial fluid and rate of accumulation, the distensibility of the pericardium, and the compliance and filling pressures of the cardiac chambers118 (Figure 12).

Table 8 Causes of cardiac tamponade

Common causes (in order of relative frequency): (1) Neoplasm/malignancy (2) Iatrogenic/trauma (3) Pericarditis (4) Tuberculosis (most common in developing countries) Less common causes (in order of relative frequency): (1) Collagen vascular diseases (systemic lupus erythematosus, rheumatoid arthritis, scleroderma) (2) Pericardial injury syndrome (3) Acute myocardial infarction (4) Aortic dissection (5) Uraemia (6) Bacterial infection (7) Pneumopericardium © ESC 2025 Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026