Diagnosing Pericarditis in the Emergency Room Setting

Initial Assessment

The European Society of Cardiology recommends that the diagnosis of pericarditis in a patient presenting to the Emergency Room with chest pain requires meeting at least 2 of 4 key diagnostic criteria: pericarditic chest pain, pericardial friction rub, widespread ST-elevation or PR depression on ECG, or new/worsening pericardial effusion 1
Obtain a focused history looking for characteristic pleuritic chest pain that may be sharp, increases with inspiration, and improves when sitting up or leaning forward, as recommended by the American College of Cardiology 2, 3
Order an ECG within 10 minutes of arrival to evaluate for characteristic changes of pericarditis, as suggested by the American College of Cardiology and the American Heart Association 2, 4
Measure inflammatory markers including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count, as recommended by the European Heart Journal 1, 5
Check cardiac biomarkers (troponin, CK) to assess for myocardial involvement, which may indicate myopericarditis, as suggested by the European Heart Journal and the American College of Cardiology 1, 6

The European Society of Cardiology recommends that to diagnose acute pericarditis, at least 2 of the following 4 criteria must be present: pericarditic chest pain, pericardial friction rub, widespread ST-elevation or PR depression on ECG, or new/worsening pericardial effusion 1
Pericarditic chest pain is typically sharp, pleuritic, and improves when sitting up/leaning forward, as described by the American College of Cardiology 2, 6
Pericardial friction rub is a scratching sound best heard at the left sternal border, as noted by the American College of Cardiology 3
ECG changes include new widespread ST-elevation (typically concave upward) or PR depression, as recommended by the European Heart Journal 1
Pericardial effusion is a new or worsening effusion on imaging, as suggested by the European Heart Journal 1

Order an ECG immediately upon presentation with chest pain, as recommended by the American College of Cardiology and the American Heart Association 2, 4
Perform transthoracic echocardiography (TTE) in all patients with suspected pericarditis to evaluate for pericardial effusion, ventricular wall motion abnormalities, and signs of tamponade, as suggested by the American College of Cardiology and the European Heart Journal 6, 7
Order inflammatory markers, including CRP, ESR, and white blood cell count, as recommended by the European Heart Journal 1, 5
Check cardiac biomarkers (troponin, CK) to assess for myocardial involvement, which may indicate myopericarditis, as suggested by the European Heart Journal and the American College of Cardiology 1, 6

Patients with high-risk features, such as fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, failure to respond to NSAIDs, elevated troponin, or immunosuppressed state, should be considered for hospital admission, as recommended by the European Heart Journal and the American College of Cardiology 1, 5, 6