Pericarditis
Pericarditis is inflammation of the thin sac that surrounds the heart. Its most recognized symptom is sharp chest pain that comes on suddenly and feels worse when lying flat.
Because chest pain is also the primary warning sign of a heart attack, pericarditis is frequently misunderstood and misidentified. Knowing the difference matters. One requires clot-busting treatment. The other requires rest and anti-inflammatory medication. Getting the wrong treatment for either is dangerous.
What Is Pericarditis?
The pericardium is a two-layered sac that wraps around the heart. It holds the heart in place, reduces friction as the heart beats, and provides a protective barrier against infection.
When this sac becomes inflamed, the layers rub against each other with every heartbeat. That friction produces sharp, stabbing chest pain. Fluid can also build up between the layers, adding pressure on the heart.
Pericarditis can affect anyone but is most common in men between the ages of 16 and 65. An estimated 28 people per 100,000 develop it each year. Most cases are mild and resolve with treatment. Some become recurrent or progress to a more serious form that requires long-term management.
In many cases no specific cause is found. When that happens, it is called idiopathic pericarditis. Viral infection is the most common identifiable cause in North America and Western Europe.
At the BaleDoneen Method, identifying inflammation-driven heart conditions early is a core part of preventing serious cardiovascular events.
Types of Pericarditis
Pericarditis is classified by how long it lasts and whether it returns after treatment.
Acute pericarditis develops suddenly and lasts less than four to six weeks. This is the most common form. It is usually caused by a viral infection and resolves with medication and rest. Most people recover fully.
Recurrent pericarditis returns after a symptom-free period following an initial episode. This happens in up to 30 percent of people within the first year after their first episode. Recurrence is driven by an abnormal immune response that continues to attack the pericardium. Each flare can disrupt daily life and lead to repeated emergency visits.
Chronic or constrictive pericarditis lasts more than three months or develops when repeated inflammation causes the pericardium to thicken, scar, and stiffen over time. The hardened sac squeezes the heart and prevents it from filling normally between beats. This is the most serious form and can lead to severe swelling, breathlessness, and heart failure if not treated.
Understanding which type is present guides how aggressively treatment needs to be applied and for how long.
Symptoms of Pericarditis
Sharp chest pain is the hallmark symptom. It typically feels like a stabbing or stabbing sensation behind the breastbone or on the left side of the chest. It often spreads to the left shoulder, neck, or both shoulders.
The pain has a distinctive pattern. It gets worse when lying flat, coughing, or taking a deep breath. It improves when sitting upright or leaning forward. This positional quality is one of the clearest ways to distinguish pericarditis from a heart attack. A person with pericarditis will often lean forward instinctively to relieve the pain.
Other symptoms include fever, fatigue, a dry cough, shortness of breath when lying down, heart palpitations or a racing heartbeat, and in more severe cases, swelling in the legs, feet, and ankles.
Severe symptoms that require emergency care include chest pain that does not improve, rapid worsening of shortness of breath, dizziness or fainting, and signs of shock such as sudden weakness and a very fast heart rate. These can indicate cardiac tamponade, which is a medical emergency.
See warning signs and symptoms and symptoms in women for guidance on what to watch for. Any new chest pain should be evaluated by a doctor promptly. Do not attempt to self-diagnose.
Why Pericarditis Causes Chest Pain
When the pericardium becomes inflamed, the two layers of the sac lose their smooth gliding surface. With every heartbeat, these irritated layers rub directly against each other. That friction generates the sharp, stabbing pain characteristic of pericarditis.
The sensation is made worse by anything that increases movement between the layers or expands the chest. Lying flat brings the pericardium closer to the chest wall and increases the rubbing sensation. Sitting forward slightly separates the layers and reduces friction, which is why this position relieves the pain.
When fluid accumulates between the layers, it initially cushions the rubbing and may reduce pain. But as fluid volume increases, pressure builds around the heart. The heart cannot expand freely to fill with blood. If fluid builds up quickly, it compresses the heart severely in a condition called cardiac tamponade. Blood pressure drops sharply, the heart cannot pump adequately, and the condition becomes life-threatening within minutes without treatment.
In constrictive pericarditis, the sac hardens permanently. The rigid shell around the heart limits how much blood the chambers can hold between beats, leading to the same downstream effects as heart failure.
Causes of Pericarditis
Viral infection is the most common cause. Influenza, COVID-19, adenoviruses, and other common viruses can trigger inflammation of the pericardium, sometimes as a direct infection and sometimes as part of the immune response after the infection has passed.
Autoimmune conditions are a major non-infectious cause. In diseases like lupus and rheumatoid arthritis, the immune system attacks the body’s own tissues including the pericardium. Autoimmune cardiovascular risk is an underrecognized driver of recurring pericarditis.
Post-cardiac injury is another important cause. The immune system can react abnormally after a heart attack or open-heart surgery, triggering pericardial inflammation days to weeks later. This is called Dressler syndrome after a heart attack, or post-pericardiotomy syndrome after surgery. Learn more about Dressler syndrome.
Bacterial infections including tuberculosis can cause pericarditis and carry a higher risk of progressing to constrictive pericarditis. Kidney failure, cancer spreading to the pericardium, chest radiation, and certain medications are additional causes. In many cases across North America, no specific cause is identified.
Risk Factors
Key risk factors for pericarditis include a recent viral illness, a history of prior pericarditis episodes, autoimmune disease, recent heart surgery or heart attack, chest radiation therapy, kidney failure, and cancer affecting the chest or surrounding tissue.
Men between the ages of 16 and 65 are at the highest risk of developing the condition. People with lupus, rheumatoid arthritis, or other inflammatory conditions are significantly more likely to experience recurrent episodes.
Having other cardiovascular risk factors such as inflammation driven by metabolic disease, insulin resistance, or chronic infection also appears to increase susceptibility to pericardial inflammation.
At the BaleDoneen Method, tracking systemic inflammation through advanced biomarkers helps identify patients whose immune systems may be in a state that predisposes them to conditions like pericarditis. Learn more about inflammation biomarkers.
Treatment and Prevention
Most cases of acute pericarditis respond well to medication and rest. The goals of treatment are to reduce inflammation, relieve pain, and prevent recurrence.
NSAIDs such as ibuprofen or high-dose aspirin are the first line of treatment. They reduce inflammation and manage pain effectively in most mild to moderate cases. They are typically taken for several weeks with a gradual taper rather than stopping abruptly.
Colchicine is an anti-inflammatory medication that is now routinely added alongside NSAIDs. It significantly reduces the risk of recurrence and speeds resolution of the initial episode. For people with recurrent pericarditis, colchicine may need to be taken for years to keep episodes from returning.
Corticosteroids such as prednisone are used when NSAIDs and colchicine are not effective or cannot be tolerated. They are powerful but carry more side effects and are associated with a higher recurrence rate when used as the primary treatment, so they are reserved for specific cases.
IL-1 inhibitors are a newer class of medications that block the specific immune pathway driving recurrent inflammation. They are used in patients with recurrent pericarditis that does not respond to standard therapy and represent a significant advance in managing this condition.
Physical activity must be restricted during the acute phase. Exercise increases inflammation and the risk of complications. Return to activity must be gradual and guided by a doctor based on symptom resolution and inflammatory marker levels. Athletes should not return to training until they are completely symptom-free and inflammation markers have normalized.
Pericardiocentesis is a procedure that drains fluid from the pericardium using a long thin needle guided by imaging. It is performed when fluid buildup is compressing the heart or when fluid analysis is needed to identify the cause. In cases where needle drainage is not possible, a pericardial window procedure creates a small opening to allow continuous drainage.
Pericardiectomy is surgery to remove part or all of the pericardium. It is reserved for constrictive pericarditis that is causing significant heart compression and has not responded to medical therapy.
Prevention focuses on completing the full course of medication, avoiding premature return to physical activity, treating underlying autoimmune conditions, and reducing triggers such as alcohol, excessive heat, and psychological stress. Learn about anti-inflammatory nutrition and stress and heart health for supportive lifestyle guidance.
Complications of Pericarditis
Without prompt treatment, pericarditis can progress to serious and potentially life-threatening complications.
Pericardial effusion, or fluid buildup around the heart, is the most common complication. Mild effusion may not cause symptoms. Rapid or large fluid accumulation leads to cardiac tamponade, where the fluid compresses the heart so severely that it cannot fill or pump. Blood pressure collapses. Without emergency drainage, this condition is fatal.
Constrictive pericarditis develops when repeated inflammation causes the pericardial layers to scar, thicken, and fuse together. The resulting rigid shell prevents the heart from expanding between beats. This leads to progressive heart failure, severe leg and abdominal swelling, and reduced exercise tolerance. It often requires surgery to remove the hardened tissue.
Recurrent pericarditis without adequate treatment becomes a cycle of repeated flares that progressively affect quality of life, restrict physical activity, and increase the cumulative risk of constrictive disease.
Early treatment prevents most of these outcomes. Waiting until symptoms are severe or completing only part of the prescribed medication course are the most common reasons complications develop.