Medscape is available in 5 Language Editions – Choose your Edition here.


Acute Pericarditis Differential Diagnoses

  • Author: Sean Spangler, MD; Chief Editor: Richard A Lange, MD, MBA  more...
Updated: Oct 06, 2014

Diagnostic Considerations

The classic feature of chest pain and dyspnea with pericarditis may be subtle and can be confused with other diagnoses, particularly in elderly individuals. Be careful not to confuse pericarditis with esophageal disorders, costochondritis, or other causes of noncardiac chest pain. Pericarditis may occur after renal transplantation, which may be related to uremia or infections (eg, cytomegalovirus [CMV]). Liver disease has been noted in asymptomatic constrictive pericarditis.

Given an overall lack of specificity of clinical features, diagnostic protocols to determine the etiology for pericarditis have been described. Following specific protocols, several investigators determined a specific etiology in 14-22% of patients. In one study, cardiac tamponade and an unfavorable clinical outcome, with persistence of fever, significant pericardial effusion, or general illness lasting longer than 1 week, was highly associated with finding a specific etiology. See an example under Workup.

Small asymptomatic pericardial effusions in patients with acquired immunodeficiency syndrome (AIDS) may not require diagnostic evaluation.[22] Large symptomatic pericardial effusions should be investigated, because two thirds of such effusions are potentially infections or neoplasms. Tuberculous pericarditis can also occur.[11]

Tension pneumothorax may mimic cardiac tamponade. Trauma ultrasonography has limited this misdiagnosis.

Elevated central venous pressure (CVP) may be absent in patients with pericarditis and preexisting hypovolemia.

Differentiating pericarditis from acute MI

Aside from clues elicited from the history and physical examination, pericarditis can be difficult to distinguish from myocardial infarction (MI) and repolarization in patients who present with chest pain and ST-segment elevation on electrocardiograms (ECGs). The potential misdiagnosis of pericarditis for acute MI has led to unfortunate complications when thrombolytic therapy has been given.

Some ECG findings that may be helpful include the following:

  • Repolarization does not progress through stages and is uncommonly associated with PR depression; serial monitoring of ECGs in young patients with chest pain helps differentiate early repolarization from acute pericarditis
  • An ST-segment–to–T-wave ratio of 0.25 or more in V 6 can distinguish acute pericarditis from early repolarization
  • The ST segment in acute MI is usually convex, bowing upward with reciprocal changes, as opposed to concave ST segments without reciprocal changes observed in acute pericarditis and repolarization
  • A study by Rossello et al indicated that unlike patients with acute ST-segment elevation MI (STEMI), patients with acute pericarditis do not show prolongation of the QRS complex and shortening of the QT interval in ECG leads with ST-segment elevation [23]

Differential Diagnoses

Contributor Information and Disclosures

Sean Spangler, MD Cardiologist, William Beaumont Army Medical Center

Sean Spangler, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians

Disclosure: Nothing to disclose.


Philip J Gentlesk, MD Director, Cardiac Electrophysiology, Section of Cardiovascular Disease, Brooke Army Medical Center

Philip J Gentlesk, MD is a member of the following medical societies: American College of Cardiology, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.


George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Vecihi Batuman, MD, FACP, FASN Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Christopher A Fly, MD Assistant Professor, Department of Emergency Medicine, Medical College of Georgia

Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Anupama Gowda, MBBS, MD Consulting Staff, Atlanta Nephrology Associates, PC

Disclosure: Nothing to disclose.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Genzyme Honoraria Speaking and teaching

G Shawn Lynchard, MD Consulting Cardiologist, Medical Director of Cardiac Care Unit, Congestive Heart Failure Clinic, and ECG and Stress Testing Clinic, Brooke Army Medical Center

G Shawn Lynchard, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Chike Magnus Nzerue, MD Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

David A Peak, MD Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Verena T Valley, MD Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital

Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

  1. Bhardwaj R, Berzingi C, Miller C, Hobbs G, Gharib W, Beto RJ, et al. Differential diagnosis of acute pericarditis from normal variant early repolarization and left ventricular hypertrophy with early repolarization: an electrocardiographic study. Am J Med Sci. 2013 Jan. 345(1):28-32. [Medline].

  2. Markel G, Imazio M, Brucato A, et al. Prevention of recurrent pericarditis with colchicine in 2012. Clin Cardiol. 2013 Mar. 36(3):125-8. [Medline].

  3. Alabed S, Cabello JB, Irving GJ, et al. Colchicine for pericarditis. Cochrane Database Syst Rev. 2014 Aug 28. 8:CD010652. [Medline].

  4. Tseng JR, Lee MJ, Yen KC, Weng CH, Liang CC, Wang IK, et al. Course and outcome of dialysis pericarditis in diabetic patients treated with maintenance hemodialysis. Kidney Blood Press Res. 2009. 32(1):17-23. [Medline].

  5. Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011 Sep 13. 124(11):1270-5. [Medline].

  6. Chraibi S, Ibnabdeljalil H, Habbal R, Bennis A, Tahiri A, Chraibi N. Pericardial tamponade as the first manifestation of dermatopolymyositis. Ann Med Interne (Paris). 1998 Nov. 149(7):464-6. [Medline].

  7. Soler-Soler J, Permanyer-Miralda G, Sagristà-Sauleda J. A systematic diagnostic approach to primary acute pericardial disease. The Barcelona experience. Cardiol Clin. 1990 Nov. 8(4):609-20. [Medline].

  8. Friman G, Fohlman J. The epidemiology of viral heart disease. Scand J Infect Dis Suppl. 1993. 88:7-10. [Medline].

  9. Silva-Cardoso J, Moura B, Martins L, Mota-Miranda A, Rocha-Gonçalves F, Lecour H. Pericardial involvement in human immunodeficiency virus infection. Chest. 1999 Feb. 115(2):418-22. [Medline].

  10. Feinstein Y, Falup-Pecurariu O, Mitrica M, Berezin EN, Sini R, Krimko H, et al. Acute pericarditis caused by Streptococcus pneumoniae in young infants and children: three case reports and a literature review. Int J Infect Dis. 2010 Feb. 14(2):e175-8. [Medline].

  11. Mastroianni A, Coronado O, Chiodo F. Tuberculous pericarditis and AIDS: case reports and review. Eur J Epidemiol. 1997 Oct. 13(7):755-9. [Medline].

  12. Imazio M, Negro A, Belli R, Beqaraj F, Forno D, Giammaria M, et al. Frequency and prognostic significance of pericarditis following acute myocardial infarction treated by primary percutaneous coronary intervention. Am J Cardiol. 2009 Jun 1. 103(11):1525-9. [Medline].

  13. Salisbury AC, Olalla-Gómez C, Rihal CS, Bell MR, Ting HH, Casaclang-Verzosa G, et al. Frequency and predictors of urgent coronary angiography in patients with acute pericarditis. Mayo Clin Proc. 2009. 84(1):11-5. [Medline]. [Full Text].

  14. Eckart RE, Love SS, Atwood JE, Arness MK, Cassimatis DC, Campbell CL, et al. Incidence and follow-up of inflammatory cardiac complications after smallpox vaccination. J Am Coll Cardiol. 2004 Jul 7. 44(1):201-5. [Medline].

  15. Lin AH, Phan HA, Barthel RV, Maisel AS, Crum-Cianflone NF, Maves RC, et al. Myopericarditis and pericarditis in the deployed military member: a retrospective series. Mil Med. 2013 Jan. 178(1):18-20. [Medline].

  16. Murthy SC, Rozas MS, Adelstein DJ, Mason DP, Calhoun R, Rybicki LA, et al. Induction chemoradiotherapy increases pleural and pericardial complications after esophagectomy for cancer. J Thorac Oncol. 2009 Mar. 4(3):395-403. [Medline].

  17. Lorell BH. Pericardial diseases. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th. Philadelphia, Pa: WB Saunders; 1997. 1478-534.

  18. Brady WJ, Perron AD, Martin ML, Beagle C, Aufderheide TP. Cause of ST segment abnormality in ED chest pain patients. Am J Emerg Med. 2001 Jan. 19(1):25-8. [Medline].

  19. Mercé J, Sagristà Sauleda J, Permanyer Miralda G, Carballo J, Olona M, Soler Soler J. [Pericardial effusion in the elderly: A different disease?]. Rev Esp Cardiol. 2000 Nov. 53(11):1432-6. [Medline].

  20. Sagristà-Sauleda J, Barrabés JA, Permanyer-Miralda G, Soler-Soler J. Purulent pericarditis: review of a 20-year experience in a general hospital. J Am Coll Cardiol. 1993 Nov 15. 22(6):1661-5. [Medline].

  21. Imazio M, Brucato A, Adler Y, Brambilla G, Artom G, Cecchi E, et al. Prognosis of idiopathic recurrent pericarditis as determined from previously published reports. Am J Cardiol. 2007 Sep 15. 100(6):1026-8. [Medline].

  22. Estok L, Wallach F. Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection. Mt Sinai J Med. 1998 Jan. 65(1):33-9. [Medline].

  23. Rossello X, Wiegerinck RF, Alguersuari J, et al. New electrocardiographic criteria to differentiate acute pericarditis and myocardial infarction. Am J Med. 2014 Mar. 127(3):233-9. [Medline].

  24. [Guideline] Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004 Apr. 25(7):587-610. [Medline].

  25. Imazio M, Brucato A, Maestroni S, Cumetti D, Dominelli A, Natale G, et al. Prevalence of C-reactive protein elevation and time course of normalization in acute pericarditis: implications for the diagnosis, therapy, and prognosis of pericarditis. Circulation. 2011 Mar 15. 123(10):1092-7. [Medline].

  26. Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, et al. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003 Dec 17. 42(12):2144-8. [Medline].

  27. Machado S, Roubille F, Gahide G, Vernhet-Kovacsik H, Cornillet L, Cung TT, et al. Can troponin elevation predict worse prognosis in patients with acute pericarditis?. Ann Cardiol Angeiol (Paris). 2010 Feb. 59(1):1-7. [Medline].

  28. Kim SH, Song JM, Jung IH, Kim MJ, Kang DH, Song JK. Initial echocardiographic characteristics of pericardial effusion determine the pericardial complications. Int J Cardiol. 2009 Aug 14. 136(2):151-5. [Medline].

  29. Hammer MM, Raptis CA, Javidan-Nejad C, et al. Accuracy of computed tomography findings in acute pericarditis. Acta Radiol. 2013 Dec 10. [Medline].

  30. Yared K, Baggish AL, Picard MH, Hoffmann U, Hung J. Multimodality imaging of pericardial diseases. JACC Cardiovasc Imaging. 2010 Jun. 3(6):650-60. [Medline].

  31. Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004 Mar 17. 43(6):1042-6. [Medline].

  32. Imazio M, Brucato A, Mayosi BM, Derosa FG, Lestuzzi C, Macor A, et al. Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown). 2010 Oct. 11(10):712-22. [Medline].

  33. Iyoda M, Ajiro Y, Sato K. A case of refractory uremic pleuropericarditis--successful corticosteroid treatment. Clin Nephrol. Apr 2006. 65(4):290-3. [Full Text].

  34. Inanç M, Akpek M, Inanç MT, Kaya MG. Acute pericarditis during 5-fluorouracil, docetaxel and cisplatin therapy. Turk Kardiyol Dern Ars. 2012 Oct. 40(6):532-5. [Medline].

  35. Imazio M, Trinchero R, Brucato A, Rovere ME, Gandino A, Cemin R, et al. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial. Eur Heart J. 2010 Nov. 31(22):2749-54. [Medline].

  36. Nakayama Y, Ohtani Y, Kobayakawa N, Kobayashi J, Kaneko Y, Aoyagi T. A case of early phase dialysis associated effusive constrictive pericarditis with distinct surgical findings. Int Heart J. 2009 Sep. 50(5):685-91. [Medline].

  37. Thompson JL, Burkhart HM, Dearani JA, Cetta F, Oh JK, Schaff HV. Pericardiectomy for pericarditis in the pediatric population. Ann Thorac Surg. 2009 Nov. 88(5):1546-50. [Medline].

  38. Bennett JA, Haramati LB. CT of bronchopericardial fistula: an unusual complication of multidrug-resistant tuberculosis in HIV infection. AJR Am J Roentgenol. 2000 Sep. 175(3):819-20. [Medline].

  39. Adler Y, Finkelstein Y, Guindo J, Rodriguez de la Serna A, Shoenfeld Y, Bayes-Genis A, et al. Colchicine treatment for recurrent pericarditis. A decade of experience. Circulation. 1998 Jun 2. 97(21):2183-5. [Medline].

  40. Adler Y, Guindo J, Finkelstein Y, Khouri A, Assali A, Bayes-Genis A, et al. Colchicine for large pericardial effusion. Clin Cardiol. 1998 Feb. 21(2):143-4. [Medline].

  41. Kuo I, Pearson GJ, Koshman SL. Colchicine for the primary and secondary prevention of pericarditis: an update. Ann Pharmacother. 2009 Dec. 43(12):2075-81. [Medline].

  42. Imazio M, Brucato A, Cemin R, et al. Colchicine for Recurrent Pericarditis (CORP) A Randomized Trial. Ann Intern Med. 2011 Oct 4. 155(7):409-414. [Medline].

Stage 1 electrocardiograph changes in a patient with acute pericarditis.
Stage 4 electrocardiograph changes in the same patient as in the previous image, taken approximately 3 months after acute pericardial illness. The patient remained symptom free despite continued T-wave inversion.
Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Courtesy of Zhi Zhou, MD.
Recording of aortic pressure showing pulsus paradoxus. During inspiration, systolic pressure declines 20 mm Hg. Courtesy of Zhi Zhou, MD.
This ultrasonogram demonstrates a normal subcostal 4-chamber view of the heart. The pericardium is brightly reflective (echogenic or white in appearance). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle. Part B courtesy of Wikimedia Commons/Patrick J Lynch and C Carl Jaffe.
H&E stain, medium power magnification showing a rheumatoid nodule in rheumatoid pericarditis, composed of histiocytes and scattered multinucleated giant cells (lower right) surrounding necroinflammatory debris (upper left).
Pap stain, high power magnification of adenocarcinoma metastatic to the pericardium on pericardiocentesis with the red arrow showing a normal mesothelial cell and the black arrowhead showing adenocarcinoma.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.